Wholesaler Application • IndieMerchandising

Company Information

Legal Company Name *

D.B.A. (if any)

Name of Parent Company

Business Type *

Tax ID / SSN / VAT *

# of Years in Business *

Date Incorporated *

State Incorporated

Phone * x

Fax

Company URL *

Email *

Store Type *

About Your Store *

Individual Responsible for Payment of Account

Name *

Title

Phone * x

Email *

Billing Address

Country *

Recipient *

Dept

Company

Address Line 1 *

Address Line 2

City *

State

Province

State / Province / Region

ZIP

Postal Code

Phone * x

Shipping Address

Country *

Recipient *

Dept

Company

Address Line 1 *

Address Line 2

City *

State

Province

State / Province / Region

ZIP

Postal Code

Phone * x

Proprietor, Partners, or Officers

1.

Country

Name

Title

Address Line 1

Address Line 2

City

State

Province

State / Province / Region

ZIP

Postal Code

Phone x

2.

Country

Name

Title

Address Line 1

Address Line 2

City

State

Province

State / Province / Region

ZIP

Postal Code

Phone x