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* All New York customers have to furnish valid Tax ID# !
* NAME OF BUSINESS :
* ADDRESS OF BUSINESS :
* City :
* Country :
* State : Other State :
* Zip Code :
PHONE# :
FAX# :
RESALE CERT# :
D.B.A / TRADE STYLE :
NAME OF OWNER 1. :
NAME OF OWNER 2. :
NAME OF OWNER 3.:
HOME PHONE :
S.S# : TAX ID :
Mailing Address :
Password :
HOW LONG IN BUSSINESS :
TYPE OF BUSSINESS: (CHECK ONE)
RETAIL WHOLESALE
ACTIVE TRADE REFERENCES
  COMPANY NAME PHONE # ADDRESS #
1.
2.
3.
BANK REFERANCES
BANK NAME:
PHONE :
ADDRESS :
CHECKING ACCT :
BANKER :
I AUTHORIZE THE BANK ABOVE TO RELEASE INFORMATION REGARDING MY ACCOUNTS.
The Customer hereby represents and warrants that the above information is true and correct. The Customer acknowledges that the information provided will be relied on be NYB International Inc. (“Seller”) and used by Seller to evaluate the customer for the establishment of credit. Seller is not obligated to grant any credit, and / or may rescind any credit line established at its sole discretion, without notice to the Customer, and without any liability to Seller, its affiliates, employees, officers, directors and /or agents. By execution below, if Seller determines to sell products to the Customer, the Customer herby agrees to be bound by Seller’s Term and Conditions of Sale(the “Terms”), which are attached here to and made a part here of as Exhibit “A ".
 
PRINT NAME:  TITLE:
SIGNATURE:  DATE:
 
 
 
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