SI03 Wholesale Account Application

Wholesale Account Application

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Business Phone Number*
Alternate Phone Number
Fax 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 NameLast Name
Phone Number*
Manager

First NameLast Name
Phone Number
Accounts Payable*

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

First NameLast Name
Authorized Purchaser 2

First NameLast Name
Authorized Purchaser 3

First NameLast Name
Purchasing Contact

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

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

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

First NameLast 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

Now create your own Jotform - It's free!Create your own Jotform