Wholesale Application

COMPANY NAME *

AMAZON SELLER NAME

DATE ESTABLISHED

STREET ADDRESS *

CITY *

STATE *

ZIP *

PRIMARY CONTACT NAME *

PRIMARY CONTACT PHONE NUMBER *

PRIMARY CONTACT POSITION/TITLE *

PRIMARY CONTACT EMAIL ADDRESS *

BILLING STREET ADDRESS (if different from above)

ACCOUNTS PAYABLE CONTACT

ACCOUNTS PAYABLE PHONE NUMBER

CITY/STATE/ZIP

ACCOUNTS PAYABLE EMAIL *

SHIPPING STREET ADDRESS *

CITY/STATE/ZIP *

RESIDENTIAL ADDRESS? *

SHIPPING CONTACT NAME *

SHIPPING CONTACT PHONE NUMBER *

SHIPPING CONTACT EMAIL ADDRESS *

BANKING INFORMATION – NAME REGISTERED WITH PRIMARY BANK

BANK CONTACT NAME

BANK STREET ADDRESS

NAME OF BANK

BANK CONTACT PHONE NUMBER

CITY/STATE/ZIP

BUSINESS/TRADE REFERENCE #1 – COMPANY NAME

STREET ADDRESS

CONTACT EMAIL

TYPE OF ACCOUNT (TERMS)

CONTACT NAME

CITY/STATE/ZIP

CONTACT PHONE

CREDIT LIMIT

BUSINESS/TRADE REFERENCE #2 – COMPANY NAME

STREET ADDRESS

CONTACT EMAIL

TYPE OF ACCOUNT (TERMS)

CONTACT NAME

CITY/STATE/ZIP

CONTACT PHONE

CREDIT LIMIT

BUSINESS/TRADE REFERENCE #3 – COMPANY NAME

STREET ADDRESS

CONTACT EMAIL

TYPE OF ACCOUNT (TERMS)

CONTACT NAME

CITY/STATE/ZIP

CONTACT PHONE

CREDIT LIMIT

We enforce a Minimum Advertised Price Policy (MAPP) *

By checking this box, you acknowledge that you have received a copy of the policy and will adhere to its requirements. Failure to do so may result in account closure.

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Please fill out the application below and submit it for review. Once approved, you will be contacted with the Wholesale Price List. We look forward to working with you.