dealercreditapplication-adiantmobile.docVIP

2201 Cooperative Way 6th Fl Herndon, VA 20170 Ph 877 980 4477 Application for a Business Account Business Information – Must be completed Legal Name: DBA Name if different from Legal Name : Billing Address: City: State: Zip: Phone: Fax: Promotion E-mail: Shipping Address: City: State: Zip: Federal Tax ID: State Tax ID: Year Business Started: Purchasing Contact: Phone: Contact Email: Accounts Payable Contact: Phone: Fax for invoices : Accounts Payable Email: Business Website: www. # of Employees: Type of Business: Own or Rent Business Premises: Home Based Business: Y N Do you sell Cellular Service: Yes: No: If yes list providers: Do you sell Cellular accessories Yes: No: Number of Locations: Sole Proprietorship: Corporation: Partnership: LLC: Other: indicate type Adiant Sales Rep: How did you hear about us? METHOD OF PAYMENT – Pick all that apply Credit Card: Please Note: We will not charge your customers credit card. Business Card: Yes: No: Business/Name on Card: Card Type: Address: City: State: Zip: Card Number: Exp. Date: Security Code: PayPal: Submit payments to: Adiant Mobile C.O.D: Money Order/Cashiers Check ONLY: C.O.D: Company Checks: NO Personal Checks CREDIT CHECK MAY BE REQUIRED - Please sign below fill out page 2 Wire Transfer/Electronic Payment: Please ask your Wilson sales rep for details. Open Account: CREDIT CHECK REQUIRED – Please fill out below, sign complete page 2 Credit Application --Please provide a copy of your business or resale license to complete the application-- I/We certify that the above information is complete and accurate. AUTHORIZED SIGNATURE:___________________________________________________________Date:______________ MUST BE SIGNED Print Name:_________________________________ Title:______________________ Application for a Business Account COMPANY CHECKS CREDIT REQUESTS BANKING REFERENCES Bank Name: Contact: Address: City: State: Zip: Phone: Fax: E