EmailMe Form - New Customer Application

Business Name *

Primary Owner Name *

Billing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Ship To Address

Same as Billing

Ship To Address (If different from billing)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Business Website

Buyer Contact Information (Person in charge of purchasing decisions. In many cases, this may be the owner.)

Name *

First Last

Email *

NOTE: This is the email address you will use to log-in, receive order confirmations, price changes, promotions, etc.

Phone *

### - ### - ####

Mobile

### - ### - ####

Fax

### - ### - ####

Accounting Contact Information

Name

First Last

Email

NOTE: This email address will receive electronic invoices and billing inquiries

Phone

### - ### - ####

Mobile

### - ### - ####

Fax

### - ### - ####

Resale Certificate

Please attach a copy of your resale / tax ID license to this application. This is REQUIRED in every state, except: AK, DE, MT, NH, OR, PA, RI, NJ, MN, non-USA.

Which of the Following Sports apparel Categories Does Your Business Sell? *

What Best Describes Your Business? *

How did you find out about A4? *

Were you contacted by an A4 Sales Representative? If so, who? *

In What Year Was Your Business Established? *

How many employees do you have? *

How many Sales Representatives do you have? *

What is Your Annual Sales Volume?

Is your Business Home Based? *

Yes

No

Payment Terms

Credit Card

If approved, you wil be able to purchase at wholesale prices via MasterCard, Visa and American Express. Your first purchase must be with a credit card. After your initial purchase you may apply separately for credit/terms by submitting a Business Credit Application.