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Company/Entity Name

Referral Code

Name of Primary Contact

Name of Primary Contact (Last)

Primary Contact's Phone Number

Email

Name of Accounts Payable Contact

Name of Primary Contact (Last)

Accounts Payable Contact's Phone Number

Accounts Payable Email

Billing Defaults

Address Line 2

Zip

Shipping Info

Different than Billing

Same as Billing

What are the top 5 products you resell?

Sale Resale Certificate

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Reseller/Tax Exempt Certificate

Please provide a PDF or Photocopy of your company's reseller/tax exempt certificate (THIS IS NOT THE SAME AS A W-9), as this is a requirement for us to have on file - since we are wholesale and do not charge sales tax

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location

email

phone

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