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New Customer Application
jose_admin
2023-11-30T18:47:24+00:00
Company Details
Company Name
*
Email
*
Years in Business
*
Contact Name
*
Fed Tax-ID
*
Years at Present Location
*
Phone Number
*
Fax Number
Type of Business
*
Sole Proprietorship
Partnership
Corporation
Franchise
Other
Nature of Business
*
Wholesale
Retail
Online Retailer
Pharmacy
Chain
Supermarket
Other
Billing Details
Address
*
Billing City, State, and Zip Code
*
A/P Contact Name
*
Account Payable Person of Contact
A/P Phone Number
*
Accounts Payable Phone Number
Shipping Details
Ship to Address
*
City, State, and Zip
*
Receiving Name
*
Receiving Person Contact Name
Receiving Phone Number
*
Receiving Contact Phone Number
Owners or Principals In Company
Must Add at Least 1 Contact
Contact 1
Name
*
Title
*
Phone Number
*
Email
*
Contact 2
Name
Title
Phone Number
Email
Contact 3
Name
Title
Phone Number
Email
Upload Resale Certificate
*
**If you do not attach your resale certificate, your account will not be processed**
Choose File
Consent Field
*
By checking the box, you are confirming that the information you have provided is accurate and you consent to our terms and conditions.
Submit
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