Rubber Wear distributor application
Company name:___________________________________ Phone: ( )__________Fax: ( )___________
Corp./Parent name:________________________________ Phone: ( )__________Fax: ( )___________
Billing address:___________________________________ Shipping address: ______________________
_______________________________________________ ____________________________________
_______________________________________________ ____________________________________
Description of business______________________________ Resale #:_____________________________
Ownership: ___Corporation (in the State of _______________?) ___Partnership: ___Sole Proprietorship
Business location: ___Owned ___Leased ___Rent ? Year established: _____________________
Annual sales for past three years:
$___________ Year:____ $____________ Year:_____ $__________Year:_____
_____________________________________________________________________________________
INDIVIDUAL OR SOLE PROPRIETORSHIP
NAME:____________________________________________PHONE: ( )________________________
RESIDENT ADDRESS:__________________________________________________________________
Driver’s License information: #______________________State:___ Exp._______ Date of birth:________
_____________________________________________________________________________________
PARTNERSHIP
NAME:_____________________________________ RES. PHONE: ( )____________________
RES. ADDRESS:_______________________________________________________________________
Driver’s License information #______________________State:____ Exp:___ Date of birth:___________
NAME:_____________________________________ RES. PHONE: ( )____________________
RES. ADDRESS:_______________________________________________________________________
Driver’s License information #______________________State:____ Exp:___ Date of birth:___________
CORPORATION
NAME:_______________________ TITLE_________________ RES. PHONE: ( )_________________
RES. ADDRESS________________________________________________________________________
NAME:_______________________ TITLE_________________ RES. PHONE: ( )_________________
RES. ADDRESS________________________________________________________________________
NAME:_______________________ TITLE_________________ RES. PHONE: ( )_________________
RES. ADDRESS________________________________________________________________________
NAME:_______________________ TITLE_________________ RES. PHONE: ( )_________________
RES. ADDRESS________________________________________________________________________
_____________________________________________________________________________________
TYPE OF ACCOUNT DESIRED
___ COD/CASH ___COD/CHECK ___OPEN 14 DAYS ___OPEN 30 DAYS
_____________________________________________________________________________________
AUTHORIZED BUYERS
1.____________________________ 2._________________________ 3.___________________________
_____________________________________________________________________________________
BANK INFORMATION
BANK NAME:___________________________________ ACCOUNT NUMBER:__________________
ADDRESS:______________________________________ ACCOUNT OFFICER:__________________
CITY, ST., ZIP :__________________________________ TYPE OF ACCOUNT:__________________
PHONE: ( )____________________________________
I hereby authorize release of account information to Sticks and Stones for the purpose of establishing a business relationship and/or extending credit. Bank will be held harmless for any decisions made based on the provided information. I agree that a copy of this authorization is as valid as the original.
SIGNED:______________________________________________________DATE:_________________
_____________________________________________________________________________________
GUARANTEE
I hereby confirm that all information offered herein is valid. I guarantee that payment for all invoices will be made in a timely manner. Should any dispute occur it shall be handled by litigation. Dealer understands that placing on order with Sticks and Stones constitutes doing business in the State of California and is therefore subject to the laws of California.
GUARANTOR NAME:______________________________ SIGNED:____________________________
TITLE:______________________________COMPANY NAME:________________________________
