EAI-JR286, Inc. – CUSTOMER SETUP FORM & CREDIT APPLICATION – JR286.COM

EAI-JR286, Inc. – CUSTOMER SETUP FORM AND CREDIT APPLICATION

Step 1 of 7

Business Information
Applicant Legal Business Name*
Applicant DBA (If Applicable)
Federal Tax ID/Registration #*
DUNS # (If Applicable)
Entity Type*
Mth/Yr Business Opened*
State of Incorporation*
Upload Retail Tax Certificate (PDF)
Max. file size: 20 MB.
Brand you are applying to Purchase*

Contact Information
Billing Contact Name*
Billing Contact Phone*
Billing Contact Email*
- Buyer Same as Billing Contact
Buyer Contact Name*
Buyer Contact Phone*
Buyer Contact Email*
Billing Address Line 1*
Billing Address Line 2
City*
State*
Zip Code*
Country*
- Shipping Address Same as Billing Address
Shipping Address Line 1*
Shipping Address Line 2
City*
State*
Zip Code*
Country*

Bank Reference
Bank Name*
Bank Contact Name*
Bank Contact Phone*
Bank Contact Email*
Bank Address Line 1*
Bank Address Line 2
City*
State*
Zip Code*
Country*

Trade References
Trade Reference 1 Business Name*
Trade Reference 1 Contact Name*
Trade Reference 1 Contact Phone*
Trade Reference 1 Email*
Trade Reference 1 Address Line 1*
Trade Reference 1 Address Line 2
City*
State*
Zip Code*
Country*
Trade Reference 2 Business Name*
Trade Reference 2 Contact Name*
Trade Reference 2 Contact Phone*
Trade Reference 2 Email*
Trade Reference 2 Address Line 1*
Trade Reference 2 Address Line 2
City*
State*
Zip Code*
Country*

* Indicates a required field.