Wholesaler Application Form

Company Name

DBA

Address

City

State

Postal Code

Telephone

Years in Business

Type of business

Corporation, Partnership or Sole Owner:

Name of accounts payable:

Street

Unit

City

State

Postal Code

Commercial/Residential

Tailgate Required?

Tax ID

I testify that I possess the authority to purchase on my company's behalf

Name of Authorized Purchaser(s)

Date

Authorized Signature

Put signature below,