Laser Light Ornaments Reseller Application

APPLICATION FOR RESELLER ACCOUNT
General Account Information
Company:			Telephone:
Address:			Fax:
Address 2:			Email:
City:			Website Address:
State:		Zip:
Owner Information
Type of Business:	Proprietorship Corporation Partnership (check one)
Retail Tax #:
Primary Owner:			Secondary Owner:
Social Security #:			Social Security #:
Home Address:			Home Address:
City:			City:
State:		Zip:	State:	Zip:
Telephone:			Telephone:
References
Credit Reference:			Name of Bank:
Contact Name:			Branch:
Address:			Contact Officer:
City:			Checking Acc't #:
State:		Zip:	How Long?
Telephone:			Telephone:
Preferred Payment Method
Select Your Preferred Method of Payment: By Invoice By Credit Card
If you selected Credit Card, please provide the information below
Card Type:			Card Number:
Cardholder's Name:			Expiration Date:
Account Security Information
Create Your Username:	(15 char. max.)		Pick A Security Question:
Create Your Password:	(6-8 char.)		Answer to Question: