RESELLER’S REQUEST INFORMATION FORM

Legal Company Name___________________________________________________________

 Address_______________________________________________________________________

 Telephone___________________________________Fax_______________________________
 

Email Address__________________________________________________________________

Resell Permit No______________________________ FED I.D. No_______________________

q Proprietorship            q Partnership               q Corporate

Name and Title of Principal, Partner or Corporate Officers:

1________________________________________ 2___________________________________

 Account Payable contact _________________________________________________________

 Purchasing contact _____________________________________________________________

Year(s) in business__________________________ Annual Sales Volume __________________

BANK REFERENCE 

Bank Name _________________________________ Account No________________________

Address _____________________________________ __________Phone_________________

TRADE REFERENCE

Company1_______________________________Phone_____________ Contact_____________

     Address ______________________________________________________________________          

Company2_______________________________Phone_____________ Contact_____________
 

Address ______________________________________________________________________

Company3_______________________________Phone_____________ Contact_____________

Address ______________________________________________________________________

Signature__________________________________ Print Name _________________________

Title______________________________________ Date ______________________________