Somadyn Wholesale Account Application

Wholesale Account Application

Company Information
Legal Business Name *
DBA
State Tax ID Number *

Billing Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Shipping Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Primary Business Phone Number *

Area Code Phone Number
Alternate Phone Number

Area Code Phone Number
Fax Number

Area Code Phone Number
Primary Business Email Address *
example@example.com

Business Presence *
Business Type/Industry *
List "Other" Business Type/Industry
Brick & Mortar Sales % *
Online Sales % *
Anticipated Order Frequency *
List "Other" Anticipated Order Frequency
Anticipated Monthly Sales *

Department Contacts
Owner *

First Name Last Name
Phone Number *

Area Code Phone Number
Manager

First Name Last Name
Phone Number

Area Code Phone Number
Accounts Payable *

First Name Last Name
Invoice Remittance Email Address *
example@example.com
Statement Remittance Email Address *
example@example.com
Authorized Purchaser 1

First Name Last Name
Authorized Purchaser 2

First Name Last Name
Authorized Purchaser 3

First Name Last Name
Purchasing Contact

First Name Last Name
Purchasing Contact Email Address
example@example.com
Marketing Contact

First Name Last Name
Marketing Contact Email Address
example@example.com
Social Media Contact

First Name Last Name
Social Media Contact Email Address
example@example.com
Warehouse or Receiving Contact

First Name Last Name
Warehouse or Receiving Contact Email Address
example@example.com

Social Media & Other Online Presence
FaceBook URL/ID
Twitter URL/ID
Instagram URL/ID
Pinterest URL/ID
YouTube URL/ID
LinkedIN URL/ID
SnapChat URL/ID
Amazon Marketplace URL/ID
Walmart Marketplace URL/ID
Ebay Marketplace URL/ID
Rakuten Marketplace URL/ID
Other Marketplace URL/ID

SAVE 25%

on monthly & annual plans

Create your own JotForm