Retailer Application

 

Phone 910- 862-2014                                                                                                     Fax   910- 879-0028

 

  

Company Name __________________________________

 

Owner/Manager __________________________________

 

Address ________________________________________

 

City _______________________ State ___________

 

Phone      (1)_______________ (2)_____________

 

Tax ID# or SS#_________________________________

 

Driver’s License Number ______________________________

                               

Initial Payment must be in Cash/Check/ or Credit Card

 

Card Type ________Card #_____________________________

 

Expires _________ CBD Code_________Zip Code_________

 

 

 

Applicants Signature Attests Financial Responsibility and Willingness to Pay Our Invoices in Accordance with our Terms.  I agree for the balance of my account due to be applied to the above listed Credit Card.  We/I understand the net due terms of Chic Designs and Agree to Abide by them.  I understand that the returned check fee is $35.00 and returned checks are payable within 5 days of notification.

 

 

 

Signature of Owner(s) ________________________________ Date _____________