Choose a Cigar

WHOLESALE ACCOUNT APPLICATION
Please complete this form as completely and as accurately as possible to ensure
quick processing and submit or use PDF version and fax to 603-507-0327

Note: Please fax copies of your Occupational / Tobacco / Resale Licenses with your application;
your application will not be processed without them.

Business Name 		PDF Version of Application [ application ]
print and fax to 603-507-0327
BILL TO ADDRESS:

Street Address
City
State
Zip

Years at this Address
Telephone
Fax
Email

Website
SHIP TO ADDRESS (IF DIFFERENT FROM BILLING):

Street Address
City
State
Zip
Corporation Incorporated Less than 12 Months
Partnership Individual

Name of Owner or Principal

Home Address
City
State
Zip

Home Telephone
Owner's or Principal's SSN
Company's FEIN ID Number

Name of Authorized Buyer
Additional Authorized Buyer(s)
BANK REFERENCE:

Bank Name
Telephone

Address
City
State
Zip

Account Number(s)
TRADE CREDIT REFERENCES: ( please list 4 references )

1.

Supplier


Account Number


Address Line 1


Address Line 2


Telephone


Fax


Number of Years

2.

Supplier


Account Number


Address Line 2


Address Line 2


Telephone


Fax


Number of Years

3.

Supplier


Account Number


Address Line 1


Address Line 2


Telephone


Fax


Number of Years

4.

Supplier


Account Number


Address Line 1


Address Line 2


Telephone


Fax


Number of Years

By submitting this form, Authorizing Signatory attests financial responsibility and willingness to pay in full within terms of sale on individual invoices. If the account is referred to a collection agency or attorney, the applicant agrees to pay all costs and expenses including attorney fees. All accounts with balances past due from date of terms are subject to a service/finance charge as stated on each invoice. In submitting this Application to open an account with Bidwell Cigar,Inc. you authorize Bidwell Cigar, Inc. to contact bank and trade references listed above. Terms refer to Net/Credit, COD, Due upon receipt or Credit Card.

Authorizing Signatory Signature
*** please sign like this /FirstName I. LastName/ using forward slashes to confirm you are authorizing this application
Date

Printed Signatory Name
Title