New Account Application Fax: 718-301-1227 / 646-292-5120 P.O. BOX 230122 BROOKLYN , NY 11223 New AccountUpdate Existing Account To ensure no delays in orders Submit a copy of Your RESALE CERTIFICATE Attach Your Latest Financial Statements if requesting Credit ( FAX TO CREDIT DEPT 718-301-1227 ) Corporate Info Bill to: Ship to: Corp Name: Trade Name: Address: Address: City: City: State/Zip: State/Zip: Email: Email: Tel: Fax: Tel: Fax: CorporationPartnershipLLCOTHER Fed ID#: State ID#: Please indicate Business Type:PharmacyReligious OnRetailWholesalerBroker Year Est.: Owner/Officer 1 : Owner/Officer 2 : Title: Title: Address: Address: City/State/Zip: City/State/Zip: Home Tel#: Home Tel#: Social sec#: Social sec#: Bank References Bank Name: Contact: Bank Address: Phone: Fax: State: ZIP Code: Type of account:CHECKINGSAVINGSLINE OF CREDITOTHERAccount# Business/trade references Company Name: Address: Phone: Fax: Contact: Type of account: Terms: Company Name: Address: Phone: Fax: Contact: Type of account: Terms: Date: Attach a file: WE WILL NOT PROCESS IF YOU DO NOT ATTACH YOUR RESALE CERTIFICATE
