Wholesale Client Input Form

Wholesale Client Input

Please complete this form while you are with the customer. The information you enter will automatically create a new account in our wholesale system and help us prepare contracts, invoices, shipping, and future support.Please take your time and verify all information before submitting.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sales Rep/Agent
Name of Business
Company Name or their DBA
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Primary Contact

First NameLast Name
Payment Preference
How do they prefer to pay?
Is This Store Part of A Group?
How Many?
ARE THEY READY TO BUY?
HOW MANY CASES TO ORDER
Standard Wholesale
Volume Discount
Commercial Fridge Program (Includes Kickback Fridge)
Distributor Rate (Includes Kickback Fridge)

Other
Confirm Fridge Count
Notes / Anything else we should know about their business?
UPLOAD A COPY OF THE STORE BUSINESS CARD

Cancelof
Terms & Conditions: All information collected is confidential. All of this information will be entered into the master Kickback CRM for interation with the client and creation of the Wholesale Account.
Should be Empty: