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Application for Membership in Block Buying Group

For your convenience, please print the Printable Application Guide This will help you to organize the required resources and materials prior to starting the Application.

Please Note: If you have branch offices, a separate application is required for each location that you wish to establish as a separate bill-to account. If your branch offices are drop-ship locations, please complete the Drop-Ship Authorization form on page 4.

Business Information

Step

* Denotes Required Fields
*Business Name:
*Business Phone:	(format: 8005551212)
Business Fax:	(format: 8005551212)
Trade Name (d/b/a):
*Address 1:
Address 2:
*City:
*State:
*Zip:
*Country:
*Email:
	(format:name@provider.com)
Previous Address:
City:
State:
Zip:
County:
*Type of business: (select one): ProprietorshipPartnershipCorporation

*State of incorporation or partnership:
*Date Business Started: (format: mm/dd/yyyy)
* Federal Tax Id OR SSN (format: 123456789)

Contact Information

Name of Individual to contact in Purchasing:
First Name:		Last Name:
Name of Individual to contact in Payables:
First Name:		Last Name:

Step