Dealer Application by 3vP085oM

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									              Equisupplies, LLC 8350 S Kyrene Rd #112 Tempe. AZ 85284
      Toll Free (888) 825-0061    Phone (480) 829-0061   Fax (480) 829-0233

                                Dealer Application
      *Please complete entire application for processing to AVOID delay of shipment*

Store Information                                             Date_____________

Year Estab._______     # of Locations:_______ # of Employees: ________

Store Name ______________________________________________________________

Store Address (ship to) _____________________________________________________
                           __________________________________________________

Bill to (if different) ____________________________________________________________________
                            _______________________________________________________________

Store Phone #___________________        Fax # ______________________

Owner(s) _________________________________________________________________

Buyer(s) _________________________________________________________________

Accounts Payable Contact ____________________________________________________

Email _____________________________ Website ________________________________

Federal Tax ID #: _________________ Resale #: __________________

Type of Business: (check all that apply)

_____English   _____Western _____Internet Based        _____Feed/Supply _____Catalog
_____Mobile    _____Pet Supply _____Embroidery         _____Gift _____Other (_____)

Key Brands Carried: _________________________________________________
 _________________________________________________________________

Bank Information

Bank Name:________________ Circle One (Checking Savings) Acct#:_________________
Address:_________________________________________ Phone: __________________

References: (must provide a minimum of 3 industry references to be considered)

1) Name ______________Phone _____________Fax____________ Contact ___________
2) Name ______________Phone _____________Fax____________ Contact ___________
3) Name ______________Phone _____________Fax____________ Contact ___________
             Equisupplies, LLC 8350 S Kyrene Rd #112 Tempe. AZ 85284
     Toll Free (888) 825-0061    Phone (480) 829-0061   Fax (480) 829-0233
 ____________________________________________________________
        *Please complete entire application for processing to AVOID delay of shipment*

Terms of Purchase (please select):

           Net 30 – Buyer is on a credit basis, and can submit check payment within 30 days from date of
invoice. If requesting terms, an additional application processing time of two weeks may be required to
finalize credit status.

         COD – Company check or money order will be collected at time of delivery. Buyer is
responsible for additional COD processing fees, currently at $9.00 per shipping carton, and subject to
change without notice. If shipment is refused at time of delivery, buyer will be responsible for COD
processing fees, shipping costs to and from buyer’s delivery location, and a 15% restocking fee.

          Credit Card – Credit card will be charged at time of shipment. Please complete additional
credit card information below:

Credit Information

Credit Card Information
Type:    _____Visa     _____MC       _____AmEx       _____Discover
Card # __________________________________________________________________
Name on Card _____________________________________________________________
CC Billing Address _________________________________________________________
                           ______________________________________________________
Expiration Date____________ Security Code_________

Authorized Signature _________________________________
Print Name __________________________________________ Title _________________
   * By signing above you are authorizing EOUS to charge your Credit Card on file per ALL
                                         Terms & Conditions*
The undersigned authorizes and releases all banks, persons, and companies listed on this
application to furnish information, as well as the authorization to check company credit. The
undersigned agrees to pay all collection costs, court costs, and legal fees incurred to collect
delinquent balances. It is specifically understood that all billing, accounts receivables & credit
functions are processed through headquarters in Phoenix, Maricopa County, Arizona.
Consequently, it is understood that in the event of suit or action, same shall take place in
Phoenix, Arizona, & that this will be at the option of Equisupplies LLC, Customer understands that
they are waiving their rights to litigate outside of Maricopa County, Arizona. Outstanding
balances are subject to a 1.5% per month finance charge. The undersigned has also read,
understands, and agrees to the Equisupplies terms and conditions of purchase.


Name                                     Title                           Date
              Equisupplies, LLC     8350 S Kyrene Rd #112      Tempe. AZ 85284
Please Make Sure A Copy of Your Resale License is included with this Application. For faster
 service, please fax completed application and all necessary forms to 480-829-0233. If you
 already have an internal document containing the required information below, you may submit
 your form in place of page one of our credit application. You will still be required to complete
                             and sign page two of our application.
                            Thank you, EOUS by Equisupplies, LLC

								
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