Warrens World Of Electronics: Credit Application

Dealer Agreement

In order for us to process your application promptly:
1) All fields marked with a RED STAR (*) must be filled out.
2) A Bank Credit Inquiry must be signed and faxed back to (718) 258-7469.
3) All NYS dealers are required to fill out and fax back a Resale Certificate.

FIRM NAME:*

D/B/A:

ADDRESS:*

CITY:*

STATE:*

ZIP CODE:*

PHONE NUMBER:*

FAX NUMBER:*

% OF BUSINESS

WHOLESALE %

RETAIL %

INTERNET %

WEBSITE ADDRESS:

E-MAIL ADDRESS:*

FEDERAL TAX I.D. #:

NAME OF OWNER:*

HOME ADDRESS:*

HOME CITY:*

HOME STATE:*

HOME ZIP CODE:*

HOME PHONE:*

SOCIAL SECURITY #:*

NAME OF BUYER:

BUYERS PHONE #:

BUYERS E-MAIL ADDRESS:

COMPANY IN BUSINESS SINCE:

AT THIS LOCATION SINCE:

TOTAL SALES PER YEAR:

List 3 Trade References (Preferably Not COD Accounts)
Trade Reference #1*

Company Name:*
Address:
City:*
State:*
Zip:
Contact Name:*
Phone Number:*
Fax Number:*
Account Number:

Trade Reference #2

Company Name:*
Address:
City:*
State:*
Zip:
Contact Name:*
Phone Number:*
Fax Number:*
Account Number:

Trade Reference #3

Company Name:*
Address:
City:*
State:*
Zip:
Contact Name:*
Phone Number:*
Fax Number:*
Account Number:

Bank Reference:*

Bank Name:*
Address:
City:*
State:*
Zip:
Contact Name:*
Phone Number:*
Fax Number:*
Account Number:*

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