Wholesale Application Form

Please fill out the following fields to apply for an account. We will contact you once we review your application
Required fields are marked with "*" next to the field name

Please select your desired account type:

Requested Credit Limit $
Company Name*	Phone*
DBA, if different from above
Billing Address*	City, State, Zip*
Shipping Address, if different	City, State, Zip
Email*
Business Location* Commercial Building Internet-Based Home Residence	Is this a Corporation? Yes No
Years at this Location Years in Business	IRS ID Number Resale Number
In the Business of	Owner/Partner/Officer SSN
Previous Addresses	Other Location Addresses
Name of Manager	Name of Buyer
Name of Owners/Partners/Officers*	Title of Owners/Partners/Officers
Bank information must be complete for consideration of open terms or company check.
Bank Name	Account Number
Bank Address	City, State, Zip
Bank Phone	Do you pledge to borrow on your accounts receivable? Yes No

Business References: Must be complete for consideration of open terms!

Name Address	Phone City, State, Zip
Name Address	Phone City, State, Zip
Name Address	Phone City, State, Zip
Name Address	Phone City, State, Zip

I/we authorize Prime Source Wholesale to investigate bank/business references listed for the purpose of obtaining an account with Prime Source Wholesale and certify the information given to be current and correct. Upon submitting this application, I/we personally guarantee payment of all invoices in full and in accordance with the terms of sale set forth by Prime Source Wholesale. Copies of Prime Source Wholesale terms and policies are available upon request, or online at https://www.primesourcerv.com/terms. I/we fully understand this to be a binding obligation, which in the event the Prime Source brings legal action to enforce payment, I/we promise to pay past due service charges/collection agency charges/attorney fees and court costs.

Owner/Partner/Officer Name**

I certify I am the Owner, Partner, or Officer of my business, and agree to the above statement.