Wholesale Application Form printable pdf download

The Irish Jewelry Company

Tel: (516) 216-4565

144 Hendrickson Ave

Fax: (516) 216-4256

Lynbrook NY 11563

irishjwlryco@optonline.net

WHOLESALE APPLICATION

All sections of this form must be completed & accompanied a W9 form.

Company Name _______________________________________________ Tax ID # _____________________

Buyer’s Name: _______________________________________ Number of Retail Locations: _____________

Company’s Address _________________________________________________________________________

City ________________________________________ State _____________ Zip Code ___________________

Year Organization Began: ____________ DBA:___________________________________________________

Phone: _________________________________ Fax: _____________________________

E-mail Address: ____________________________________________________________________________

Website Address: ___________________________________________________________________________

Business Description: ________________________________________________________________________

__________________________________________________________________________________________

OWNER INFORMATION (Must be completed for all partnerships and sole proprietorship and corporations)

Limited Liability Corporation ( ) Partnership ( )

Sole Proprietorship ( )

Owner’s Full Name ________________________________________________________________________

Owner’s Address __________________________________________________________________________

City _______________________________________ State _____________ Zip Code ___________________

Partner’s Full Name (If Partnership) ___________________________________________________________

Partner’s Address __________________________________________________________________________

City _______________________________________ State _____________ Zip Code ___________________

BILLING:

Credit Card Holders Name: __________________________________________________________________

Credit Card Type: VISA ________ MASTERCARD ________ AMEX ________ DISCOVER__________

Credit Card Number:_________________________________________________ EXP Date:______________

Security Code:_____________ Authorized Signature______________________________________________

Billing Address: ____________________________________________________________________________

Town:___________________________________________ State :______________ Zip Code:_____________

Wholesale Application Form