| This information is for CSD's internal use only, so
that we may better serve you, our customer. Please update us if any
information on this form changes so that we may keep your file current.
* Denotes required fields
|
LOGIN INFORMATION
|
| Username |
* (at least 5 chrs.) |
| Password |
* (at
least 5 chrs.) |
| Re-type Password |
* |
|
CUSTOMER ACCOUNT INFORMATION *
|
| Firm Name |
* |
| Description of Business |
|
| First Name |
* |
| Last Name |
* |
| Phone |
* |
| Fax |
|
| Email |
* |
| Website |
|
| Address |
* |
| City / State |
*
Zip
* |
| Country |
|
| Credit Card # |
Exp Date
/
|
|
OWNERSHIP
|
| Owner's / President's Name(s) |
|
| Address |
|
| City / State |
Zip
|
| Phone |
(
)
-
|
| Fax |
(
)
-
|
| Year Established |
Resale No.
(CA only) |
|
TRADE REFERENCES
|
| REFERENCE 1 |
| Ref. Name |
|
| Ref. Phone |
(
)
-
|
| Ref. Fax |
(
)
-
|
| Ref. Address |
|
| REFERENCE 2 |
| Ref. Name |
|
| Ref. Phone |
(
)
-
|
| Ref. Fax |
(
)
-
|
| Ref. Address |
|
| REFERENCE 3 |
| Ref. Name |
|
| Ref. Phone |
(
)
-
|
| Ref. Fax |
(
)
-
|
| Ref. Address |
|
|
BANK REFERENCE
|
| Authorization: The bank and trade references are
authorized to release requested credit information to California Specialty
Distributors. |
| Bank Name |
|
| Bank Phone |
(
)
-
|
| Bank Fax |
(
)
-
|
| Bank Address |
|
| Bank Account No. |
|
