Company Name:

D/b/a (if different from above):

Mailing Address:   Ship to Address:

Phone Number:      Toll Free Number:      Fax Number:

 Ownership      Corporation      Partnership      Proprietorship      Other   

Type of Distribution:     Full Service        Over the Counter          Wholesale           Salon Chain

 Number of Stores:       Professional Only                 Retail  

 Year Established:                     Years at Present Location:

 Owners Name(s) (President):   Buyers Name(s):

Accounts Payable Contact:   

Business License Number:       Resale Number:   

 Bank References

Bank Name:              Account  Number:

Address:                Contact Person:

City, State, & Zip:       Bank Phone:

Business References

(List Only those You Buy From on Open Account):

 Name:             Name:

Address:          Address:

City, State & Zip:    City, State & Zip:

Phone:                    Phone:

Name:             Name:

Address:          Address:

City, State & Zip:    City, State & Zip:

Phone:                    Phone:

I Hereby authorize you to contact the references given, including our bank to obtain sufficient and satisfactory credit information. 

 Agree  YES                   NO

Title:                             Date: