New Account
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Legal Name of Company
*
Billing Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Business Phone Number
*
Date Business Started
Primary Contact Name
*
Requested Credit Limit
*
Is Your Business:
*
Sole Proprietorship
Corporation
Partnership
If Subsidary, Name of Parent Company
Buying Group
None
Brand Source
FMG
Nationwide
Furniture First
Choose any AMI. *Optional
DBA
*
Shipping Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Business Fax Number
Business Email
*
Primary Contact Phone Number
*
State Resale License Number
*
Federal ID #
*
DUNNS #
Rep Name
Full Name. *Optional
Disclaimer
Buyer is requesting that Seller provide goods to Buyer on an open account. By signing below, Buyer authorizes Seller to request and obtain a credit report on Buyer with any and all credit reporting agencies deemed appropriate by Seller. This authority shall remain open and valid unless revoked by Buyer in writing, and Seller may periodically request credit reports on Buyer as Seller deems appropriate or necessary. Nothing herein shall require that Seller extend any credit to Buyer whatsoever, and to the extent that Seller does sell any goods to Buyer on account, nothing herein shall require that Seller continue to sell any additional goods to Buyer on account.
Buyer agrees to the above terms of sale and certifies that the facts set forth in the above credit application are true and complete.
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Signature #1
*
Clear Signature
Signature #2
Clear Signature
Date / Time
Date
Time
Date / Time
Date
Time
Submit