Gold Retailer Company Application - Purple Sticky Salvia™

Store Name *

Owner: / Corp name *

Store Buyer: *

Store Phone: *

State Resale / Tax ID: *

Date

Buyers Email:

Ship To:

Address Line 1

Address Line 2

City

State

Zip Code

Can you recieve mail at your shipping address?

Yes
No

If no, Please provide a mailing address

Address Line 1

Address Line 2

City

State

Zip Code

Store Hours:

Preferred Payment:

FOR CHARGE CARD PAYMENTS, YOU MUST HAVE A COMPLETED CHARGE CARD AUTHORIZATION FORM ON FILE. FOR COD COMPANY CHECK WE MUST HAVE A COMPLETED CHARGE CARD AUTHORIZATION FORM & COMPANY CHECK GUARANTY OF PAYMENT. AGREEMENT OF TERMS & CONDITIONS

Name: *

Signature:

Date:

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