Catalogs
New Credit Application Form
New Credit Application Form
(To Comply With THE USA PATRIOT ACT)
Registered legal name
D.B.A / trade style
Physical address
City
state
zip
Mailing address
Phone
fax
Mobile no
Web
E-mail
Fed tax id
Resale tax#
JBT Id
Have you instituted an anti-money laundering program?
How did you hear about us?
Facebook username
Type of business
RETAILER
WHOLESALER
ETAILER
Year business started
Years at present location
Legal status of organization
PRIVATE CORP
PARTNERSHIP
INDIVIDUAL
List of owners or authorized persons to place orders
DESIGNATION
FIRST NAME
LAST NAME
MOBILE NO.
**to comply with the usa patriot act**
kindly provide us a copy aml letter & any govt. Issued photo id card of the owner/authorized buyer** ** (i.e. Driving license, passport, state id.) **
Trade references: (list at least 5 references please)
#
Company Name
phone#
Email
1
2
3
4
5
By signing, i confirm that the above details are true and correct
Business entity name
Sign of authorized signator
Date
print name
I accept and read the
Agreement
Submit
