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New Customer Application:

Please select with of the following applies to you:

Wholesale Distributor
Retailer

Please select your SALES REPRESENTATIVE:

Omer Qadeer
Shwetah Mehra
None
Other

COMPANY INFORMATION Legal Business Trade Name(applicant):
D/B/A:
Years at present location: Is This a Residence?: Yes No

Address:
suite:
City:
State:
Zip/Postal Code:
Country:
Phone:
Fax:
Email Address:
BILLING INFORMATION A/P Contact: Phone: Billing Address:
suite:
City: State: Zip Code: Country:
SHIPPING INFORMATION Shipping Contact(s): Phone Number: Shipping Address:
suite:
City:
State:
Zip:
Country:

Drop Ship Authorization: Yes No

Comments:
BUSINESS INFORMATION

Type of Business:

Corporation
LLC
LLP
Partnership
Proprietorship
Other


Date Incorporated:(mm/dd/yyyy)
State of Incorporation: D&B Number: Federal ID: Do you Own or Rent?: Own Rent
TRADE REFERNCES
(Related industry purchases during the past 12 months)
Reference 1:
Business Name: Address: Contact Person: Phone: Account:
Reference 2:
Business Name Address Contact Person Phone: Account:
Reference 3:
Business Name: Address: Contact Person: Phone: Account:
PAYMENT: PAYMENT TYPE:
(Please check the one that you would like to request):
Wire Transfer/ACH
COD  (Certified Check/Money Order)
BANK REFERENCES 1 Bank Name: Complete Address: Account Number(s): Years dealing with this bank: Bank officer to Contact: Phone (inc. area code): Fax (inc. area code):
BANK REFERENCES 2 Bank Name: Complete Address: Account Number(s): Years dealing with this bank: Bank officer to Contact: Phone (inc. area code): Fax (inc. area code): AUTHORIZED BUYERS
AUTHORIZED BUYER 1
Name: Phone: Email Address:
AUTHORIZED BUYER 2
Name: Phone: Email Address:
AUTHORIZED BUYER 3
Name: Phone: Email Address:
PRINCIPAL INFORMATION
Owner/Partner(s) Name: Social Security:
Drivers License:
Address: City:
State: Zip Code:
Country:

Have any of the partners/owners/guarantor(s) of the company ever filed for bankruptcy:  Yes  No

(if Yes, please fill date filed and status fields.)
Date Filed:(mm/dd/yyyy) Status:
Name of Share holders/partners:
1.      2. 3.

Applicant

Printed Name:
Title:
If you need a printable copy of the form, kindly email us at info@mobilehype.com.


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