JEWISHCARD Wholesale Request Form

PLEASE PRINT OUT THIS FORM AND FAX TO 1-(831)-469-8803

Contact Person's Name:______________________________________________________________

Name of Business:__________________________________________________________________

Address:__________________________________________________________________________

City:_______________________________________ State:__________________ Zip:___________

Phone: (______)_________________________    Fax: (______)_____________________________

email: __________________________________  URL:____________________________________

Type of store:_____________________________________ Date Established__________________

I prefer to be reach by  ___ email    ___Phone  Best time to reach me is _____________________

Resale #______________________________   

How did you find us?

___Internet Search (where)_____________________   ___Linked from other site(where)____________________

___Printed ad in:_____________________________   ___Other________________________________________

Billing Preference: Please check one: Credit Card:_________ or Open Credit Account__________

If you wish to pay with credit card you do not need to fill out the lower part of this form.

If you wish to establish an open credit account with us you must complete the following questions.

Your Accounts Payable Representative's Name:__________________________Phone_____________

#1) Trade Reference Name_________________________________ Account #_________________

Phone: (______)________________________ Fax: (______)_________________________

#2) Trade Reference Name_________________________________ Account #_________________

Phone: (______)________________________ Fax: (______)_________________________

#3) Trade Reference Name_________________________________ Account #_________________

Phone: (______)________________________ Fax: (______)_________________________

#4) Trade Reference Name_________________________________ Account #_________________

Phone: (______)________________________ Fax: (______)_________________________