Application for Biro88™ Authorized Retailership |
Tell us about your company
Note: You can print this form, fill it out and Fax to: (212) 764-4506 |
* Your Name:
|
|
* Title: |
|
* Company Name:
|
|
|
|
* Street Address:
|
|
* Street Address:
|
|
* City:
|
|
* Zip:
|
|
* State/Province: |
|
* Country:
|
|
* Phone:
|
|
|
Fax:
|
|
*Name of Principal:
|
|
*Type of Entity : |
|
*Years In Business:
|
|
*Years at Current Address: |
|
Listed in JBT:
|
|
*Account Payable Contact: |
|
What brands do carry in your store?
|
|
JBT #
|
|
*Website Address:
|
|
|
|
|
*Please supply pictures of your store
|
|
*Email Address: |
|
| |
|
|
|
|
Bank References |
Bank 1:
(Name, address, Phone & Contact) |
|
Bank 2:
(Name, address, Phone & Contact) |
|
Trade References
|
* Reference 1:
(Name, address, Phone & Contact) |
|
* Reference 2:
(Name, address, Phone & Contact) |
|
* Reference 3:
(Name, address, Phone & Contact) |
|
* Reference 4:
(Name, address, Phone & Contact) |
|
|
| |
| |
 |
|
| |
| *Security code: | |
|
|
