Account Application
Account Information
Name of Applicant :
Name of Legal Entity :
Bill-To Address :
City/State/Zip :
Set as Primary Bill To? Yes
Ship-To Address :
City/State/Zip :
Set as Primary Ship To? Yes
Business Phone : - - ext
Business Fax : - - ext
Email Address :
Contact Person :
Exempt from sales tax :
(AR,CA,IL,MO,NV,TN only)
Yes No (If yes, please mail or fax in Sales Tax Exemption Certificate)
Bill through Buying Group or Co/Op?
Yes No
Group Name
Member ID
Business Organization
OD MD Lab Optician Retailer Distributor
Date Formed :
Sole Proprietor Partnership Corporation LLC PA
Federal Tax ID :
Resale Number :
Name of Business Owner #1 :
Name of Business Owner #2 :
Trade References
Reference : Account # : Phone :
Reference : Account # : Phone :
Reference : Account # : Phone :
Authorization
I authorize I-deal Optics Holdings Inc to obtain credit information from the above listed refrences and from any credit-reporting agency. I have read the terms and conditions and acknowledge such terms and conditions govern my relationship with i-dealoptics. My signature below indicates acceptance of and agreement to terms and conditions and my guarantee of buyer's obligation. It is further understood and agreed that should this account not be paid to terms, the undersigned will pay interest at the highest rate allowed by law in the State business resides. If the account is turned over to collection, I accept and will pay resonable attorney or collection fees.
Name : Date :
Re-enter security code :image
* Required Fields