collections, inc.
New Dealer Application p.o. box 6757, Miramar Beach, Florida, 32550 Toll Free 800.834.7044 Fax 866.309.2910 www.noteworthyonline.com
COMPANY NAME:
BILLING ADDRESS:
Tel:
Street:
Fax:
City, State, Zip:
Email:
SHIPPING ADDRESS:
Website:
Street: City, State, Zip:
OWNER’S NAME(S):
Years in Business:
(Home) Street:
Sole Proprietorship/Partnership/Corporation
City, State, Zip:
Sales Tax ID Number:
Home Phone:
Accounts Payable Contact:
We will also need a copy of your Business License. BANK NAME: Tel: (
Bank Address:
)
Account #:
Contact Name:
PAYMENT: Visa
Mastercard
Credit Card number:
American Express
Expiration Date: Cardholder Name: Authorized Signature:
PLEASE SUBMIT THIS FORM ALONG WITH YOUR OPENING ORDER FOR ONE OF THE FOLLOWING: an album order a cd album order a display unit order a $150.00 blank stock order Net 30 Terms not available for New Accounts.