My account

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Last Name *

Street Address

Address 2

State / County

Town / City

Postcode / Zip

Company

Phone

Additional business fields:

Select User Role* ---Select--- Subscriber b2b_whole_sale

Business account?

Business name (D/B/A)

Head bookkeepers name

Head bookkeepers phone

Head bookkeepers mail

Bussines type Corporation Proprietorship Partnership

DBA name

Shop city

How long in business

At this location

Shop specialty

Bank name

Bank contact

Bank phone

Bank address

Major suppliers

Supplier Name

Supplier Address

Contact

Phone

Email

ACCT

Claims

Are any attorneys or collection agencies golding claims against you? Yes No

Details

Information beneficial in helping establish your credit line

Retail certificate

W-9

Tax exempt? * yes no

Tax ID

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Representative Jil Brandon