Reseller Information

Legal Business Name:
DBA (if applicable):

Address:
City:		Zip:		State:	Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Phone:		Fax:
Website:

Reseller Certificate #:

based in

Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

 Key Company Contacts:

	President	Customer Service	Purchasing
Name:
Email:
Accounting Contact:
Name:
Email:		Phone:	Fax:

In an effort to conserve paper, EZ Hidewire will send the invoices via email. If you would prefer to receive the invoices via US mail, please check this box.

EZ Hidewire will send invoices to the Accounting Contact email listed above. If you would like the invoices to be sent to a different email address instead, please enter it here:

 How did you hear about EZ Hidewire?

Magazine      Trade Show      EZ Hidewire Email Campaign      Online Search

Referred by      Other 

 Purchasing Information:

Business Entity:  Incorporated   Sole Proprietor   Partnership   DBA  

Year Established:			# of Employees:
D&B Number:			Fed Tax ID:

Payment Preference

Credit Card   Prepayment   Open Terms   Other:

Amount of Credit Requested: $

I agree that if approved, Credit Terms will be NET 30 days

** Minimum order requirement of $250 for first Purchase Order **

 Bank Reference:

Bank Name:    Account #:

Contact Person:   Phone:   Fax:  

 Credit References: