MERCHANDISE INC.

, PO BOX 10, MIAMITOWN, OHIO 45041

PHONE:1-800-819-8615 FAX:1-513-353-3970

NEW CUSTOMER APPLICATION

CUSTOMER PREFERRED PREFERRED ORDER SUBMISSION
BUSINESS TYPE:
DELIVERY METHOD METHOD

BILL TO ADDRESS:
COMPANY NAME:
Do you want automatic item
substitutions? (Y/N)
ADDRESS 1:

ADDRESS 2:

CITY: STATE: ZIP:

COUNTRY TERRITORY

PHONE: FAX: EMAIL:

SHIP TO ADDRESS:
NAME:
Is this a RESIDENTIAL Address
(Y/N)
ADDRESS 1:

ADDRESS 2:
(If ARIZONA, please submit a copy of your Arizona Board of
CITY: STATE: Pharmacy Permit with this application.)

COUNTRY TERRITORY ZIP:

PHONE: FAX:

Are you Exempt from Sales Tax? If YES, please include a copy of your TAX EXEMPT CERTIFICATE with this application.

CHEP Pallet Acct. Number: (if any)

NAME: PHONE # : EMAIL ADDRESS:

Owner / Manager

Buyer Name

AP Manager Name

Receiving Dept-Name

BANK: ACCOUNT NO.:

PHONE NUMBER: TYPE ACCOUNT:

CONTACT PERSON: EMAIL:

CREDIT REFERENCES:
Creditor's Name Contact Person Phone # Email Address:

PLEASE NOTE: *Payment Terms are CASH IN ADVANCE via ACH or Wire Transfer.
BY SIGNING BELOW, I HEREBY AUTHORIZE MERCHANDISE INC. TO RECEIVE CREDIT
INFORMATION CONCERNING MY BUSINESS FROM THE ORGANIZATIONS LISTED ABOVE.

(Authorized Signature) (Date)

SPECIAL INSTRUCTIONS:__________________________________________________________________________________
_______________________________________________________________________________________________________
FOR OFFICE USE ONLY:
PRICE
QUOTE:______ RETAIL Z-:______ MOQ:_______ FREIGHT:_______ SALES ID:_______ TERMS:_______ COMMS:________RESTRICTED: _____