Wholesale Application for Parma!

"*" indicates required fields

Name*

First Last

Company Name*

Title

Email*

Primary Phone*

Billing Address*

Street Address Address Line 2 City State ZIP Code

Is Shipping same as the Billing address?*

YES

Shipping Address*

Street Address Address Line 2 City State ZIP Code

Website*

Website Address / URL

# of Stores & Locations*

Share Number of stores in first column and then list the remainder with Name and location of each. (City/State/Zip Code)

State of Incorporation*

Federal Tax ID #*

Resale #*

Business License # (if applicable)

Description of Company & Service Provided

Business References

List names, phone numbers & account numbers.

I plan to sell items online.

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Enter your name/signature*

Date*

What does 4 + four = ?*

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Comments

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