New Account Application Form
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1New Account Application
P
LEASE FILL IN ALL BLANK FIELDS
Account Name:___________________________________________________________________________
Type of Account: (Please check one) ____ Retail Store
____ Online Store
____ Physician/Practioner
Shipping Address:_________________________________________________________________________
City:___________________________________________ State:______________ Zip:__________________
Phone:_____________________________________ Fax:_________________________________________
Contact(s):_______________________________________________________________________________
Email:___________________________ Website (required for online retailers):_________________________
Tax ID:_______________________________ Seller’s Permit:______________________________________
P
:
AYMENT TERMS
(A
MUST
C.O.D. NO
)
LL FIRST ORDERS
BE PAID BY CREDIT CARD OR
EXCEPTIONS
ACCOUNTS WILL NOT BE PLACED ON TERMS UNLESS REFERENCES AND CREDIT APPLICATION ARE FILLED AND RETURNED
P
30
LEASE BE ADVISED CREDIT CARDS ON FILE WILL BE CHARGED FOR ALL INVOICES PAST DUE IF NO PAYMENT IS RECEIVED AFTER
DAYS
CREDIT CARD:
N
:___________________________________________________________________________
AME ON CARD
C
#:______________________________________________________ E
. D
:__________________
ARD
XP
ATE
This is authorizing Paradise® to automatically charge to your account when orders are placed. By signing below, I agree to these terms.
C.O.D.
: please provide credit card information. Card will only be charged if check is returned or account
ACCOUNTS
is delinquent. By signing below, I agree to these terms.
B
A
: (I
,
________) I
,
:
ILLING
DDRESS
F SAME AS ABOVE
MARK HERE
F NOT
PLEASE PROVIDE
________________________________________________________________________________________
________________________________________________________________________________________
Signature of cardholder (
):___________________________________________________________
REQUIRED
Please note: Terms are not available to new customers until application is approved. Please allow 60-90 days for
approval.
:
ACCOUNTS PAYABLE INFORMATION
Contact Person:________________________________ Phone:_______________________ Ext:__________
B
.
Y SIGNING BELOW YOU ARE CONFIRMING THAT ALL INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT
Signature:_________________________________________________________ Date:__________________
Print Name:______________________________________________________________________________
F
:
OR REP USE ONLY
Rep Assigned:________________________________
Territory:________
Pricing:_______________
F
:
OR OFFICE USE ONLY
Entered by:_________
Credit App. Rec’d:_____
Terms Granted:_______________
Resale Cert. Rec’d:_____
License Rec’d:_____
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Parent category: Business