COMPLETE THE FOLLOWING FORM FOR A
NEW ACCOUNT
* - Indicates required fields |
| *
What Credit Terms are you requesting? |
Prepay (Credit Card, Wire Transfer)
COD (Cashier's check)
COD (Company check) |
| *
Resale Certificate #: |
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| *
Legal Business Trade Name: |
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| D.B.A.: |
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| *
Street Address: |
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| *
City: |
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| *
State: |
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| *
Zip: |
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| Is this a Residence? |
Yes
No |
| *
Phone: |
(Please do not list toll-free or cell numbers) |
| Fax: |
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| County: |
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| Web Site: |
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| * E-mail Address: |
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| Billing Information |
| A/P Contact: |
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| Phone: |
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| *
Billing Address: |
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| *
City: |
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| *
State: |
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| *
Zip: |
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| Shipping Information (leave blank
if same as above) |
| Shipping Contact: |
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| Phone: |
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Shipping Address:
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(for multiple locations
- attach a sheet to the form when submitted by fax or mail.) |
| City: |
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State: |
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| Zip: |
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| * Drop Ship Authorization |
Yes, I authorize drop shipments
No drop shipments, please. |
| Business Information |
| This business is a... |
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| *
Date Started |
Month
Year |
| *
State of Incorporation |
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| D&B #: |
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| Fed ID #: |
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| Are you a: |
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| Parent Company Name: |
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| Address: |
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| City: |
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| State: |
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| Zip: |
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| Parent Company D&B
#: |
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| |
| Landlord Information |
Rent
Own |
| Years at this address: |
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| Landlord Name: |
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| Landlord Phone |
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| Address: |
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| City: |
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| State: |
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| Zip: |
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| Principal Information (Attach a separate
sheet if needed) |
| *
Owner / Partner / Officer Name: |
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| % Ownership: |
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| Social Security #: |
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| Driver's License # & State: |
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| Address: |
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| City: |
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| State: |
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| Zip: |
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| * Have you ever filed for
bankruptcy? |
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| Date Filed: |
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| Status: |
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| Which category best describes your company's business? |
|
| Bank References (Please complete fully,
Include a separate sheet if needed) |
| REQUIRED TO OPEN AN ACCOUNT |
| *
Bank Name: |
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| Account Officer's Name: |
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| * Checking Account#: |
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| *
ABA/Routing Number: |
(9-digit number which can be found at the bottom
of your check.) |
| |
| Address: |
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| City: |
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| State: |
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| Zip: |
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| *
Phone: |
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| Fax: |
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| Trade References (Related industry
purchases during past 12 months) |
| * Name: |
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| Address: |
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| City: |
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| State: |
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| Zip: |
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| * Phone: |
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| Fax: |
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| Account #: |
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| * Name: |
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| Address: |
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| City: |
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| State: |
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| Zip: |
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| * Phone: |
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| Fax: |
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| Account #: |
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| |
| * Name: |
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| Address: |
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| City: |
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| State: |
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| Zip: |
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| * Phone: |
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| Fax: |
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| Account #: |
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| Credit Card Information |
| Select a Card: |
|
| Card
Number: |
(Numbers Only) |
| Expiration Date: |
/
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| Name on Card: |
I am an authorized signer on the
above card and hereby give permission to bill my credit card when requested. |
| Billing Address for Card
Holder: |
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| City: |
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| State: |
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| Zip: |
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| Authorized Buyers |
| Name: |
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| Phone: |
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| Fax: |
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| |
| Name: |
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| Phone: |
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| Fax: |
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| |
| Name: |
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| Phone: |
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| Fax: |
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PLEASE NOTE:
Do NOT print out this
page. Upon completion of this credit application, click the Continue
button above.This will continue to a new browser window with your application
for you to print out, sign and fax or mail to StarPCS for approval.
Be sure to sign on all necessary spaces.
StarPCS, Inc. is a wholesale distributor. We can only
sell products to resellers. If you do not have a reseller tax ID number,
you will not be able to purchase from StarPCS, Inc.
Please submit a copy of a voided business check for faster processing |
