Account Information New___ Acct.

#____________________ Date: 28 / 05 / 20____

22

Legal:Store / Business / DBA Name: __________________________________________________________

SKYROX COMPANY CORP

Name of Corporation (if different):______________________________________________________________

165 HENRY STREET, APT 102
Primary Address: __________________________________________________________________________
City/State/ZipCode/Country:__________________________________________________________________
NEW YORK, NY 10002, USA

814 247-7032
Business Phone: (_________) ____________________ Business Fax: (_______) _______________________
Web site: www._____________________________________________
www.skyroxmart.com

Owner Name(s): ______________________________

MD SHAHNAWAZ Owner’s home phone: (______)__________________
Owner’s cell phone: (______)__________________Owner’s e-mail:_________________________________
procurement@skyroxmart.com

Wholesale Authorization: Petersen-Arne sells only wholesale (no retail) to businesses authorized to
purchase tax free according to the laws of their incorporated State. We do not require a physical store
location, but do require legal tax exempt paperwork according to your state’s laws.
Authorizing State: _____________________________________ For all business documents, we need a copy
sent either by fax or scanned and emailed to sales@pa-dist.com or customerorders@leisurearts.com
88-2016352
Business License #: __________________________________________________Expiration: _____________
Sales Tax # or Seller’s Permit Number # _________________________________
88-2016352
45999-0023 Expiration: ____________
Reseller’s Tax ID or Exemption Certificate: _______________________________
45999-0023 Expiration: ____________

Shipping: Ship to Name (if different):________________________________Phone:(____)_______________

Street Address (if different) : __________________________________________________________________
Shipping address is:  Residential  Commercial  Other __________________________________
International Importer’s Tax Code for Customs (if applicable):_______________________________________

Billing: Billing Address (if different) ____________________________________________________________

Accounting Phone: (_______) _____________________ Accounting Fax: (_______) ____________________
Bookkeeper name: _________________________ Accounting e-mail: _______________________________

Purchasing: Buyer name(s): ________________________________________________________________

MD SHAHNAWAZ

Product Info Mailing Address (if different): _______________________________________________________

Buyer e-mail: __________________________________Buyer
procurement@skyroxmart.com Phone: (______) ________________________
 Yes, add me to the New Product Announcement newsletter e-mail: ______________________________
Additional newsletter recipients e-mail: ________________________________________________________

Rev. 4/16/21 sales@pa-dist.com www.pa-dist.com

customerorders@leisurearts.com www.leisurearts.com
Account Information Form, page 2 (cont.)

How did you hear about us? (Please select one)

__ Tradeshow (specify)_______________________
__ Referral from another customer or vendor, who? ___________________________________________
Referral from another customer
__ Internet Search
__ Ad __ Other (specify) _____________________________

Check one:
__ Crafts Store __ Yarn / Needlework Shop
__ Quilt Shop __ Variety / Drug Store __ Online Retailer
__ Fabric Store __ Retailer/Store Front __ eCommerce
__ Home-based Business __ Fine Art __ PA ship directly to Amazon FBA

Payment Preferences:
1) __ Pay Pal (send payment to paypal@petersen-arne.com)

2) __Visa / MasterCard credit cards only - (fill in information below)

(Debit card users should call customer service.)

3) __ Net 30 Credit - (Fill out separate application)

Method to use pending credit approval process? __________________________________________
Credit card & Bank account number
4) __ ACH

Comment or note to Customer Service: __________________________________________________________

Credit Card Information: (circle one) Visa / MasterCard

Card number will be given when the account opened
Cardholder Name (exactly as it appears on the card):_______________________________________________
Credit Card Number: ___________-____________-__________-__________ Expiration: _______/______
Required Card Billing Address: _________________________________________________Zip_________
Required 3-Digit Security Code: ____________
Required Signature
Authorizing card billing on shipment: ______________________________________________________

Office Use only:

Sales Territory______________________________ CS Rep ___________________ Order Pending? Yes / No