NET 30 Dealer Application

Required before submission: IRS SS-4 confirmation, state resale permit, completed resale certificate, current W-9, and bank/trade references.

Applicant

First Name

Last Name

Phone Number

Company

Company Name (Full Legal Name)

Company DBA

DUNS Number

Federal Tax ID / EIN

Legal Business Formation

Billing Email

Type of Business

Years in Business

Number of Employees

Number of Locations

Sales Volume Last Fiscal Year

Requested Credit Limit

Top Selling Product Last Year

Describe Your Geographic Territory

Legal Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Owners and Contacts

Are there Multiple Owners?

Additional Owner First Name

Additional Owner Last Name

Additional Owner First Name

Additional Owner Last Name

CEO/President First Name

CEO/President Last Name

CEO/President Phone

CEO/President Email

CFO/Controller First Name

CFO/Controller Last Name

CFO/Controller Phone

CFO/Controller Email

Purchaser First Name

Purchaser Last Name

Purchaser Phone

Purchaser Email

Credit Details

Have you or any affiliates filed bankruptcy?

If bankruptcy was filed, what state and year?

Preferred Shipping Carrier & Account Number

Required Documents

I understand my application will be delayed if all required documents are not included.

Federal/IRS SS-4 Confirmation

State Business Resale Permit / License / Registration / Certificate of Authority

Completed Resale Certificate

Current Year's W-9

Bank and Trade References

Authorization

Signature

Signer Title

I certify this information is accurate and authorize Olympian LED to review this application.

I authorize credit, bank, and trade reference verification.