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 603-372-0327

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 603-372-0327
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

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