. MARCHON EYEWEAR 35 HUB DRIVE MELVILLE, NEW YORK 11747 TEL# 1-800-442-4261 FAX# 1-800-442-4262
ACCOUNT PROFILE/CREDIT APPLICATION COMPANY NAME _____________________________
DBA ________________________________
ADDRESS ____________________________________________________________________________ CITY _________________________________ STATE ________________________ ZIP _____________ TELEPHONE # (________) ____________________ CHECK ONE:
Corporation _____
FAX #
Partnership _____
(________) ____________________
Sole Proprietor _____
GROUP NAME (If any): _________________________________ EMAIL ADDRESS _______________ CHECK ONE:
RETAIL X
OWNERS/OFFICERS/PARTNERS NAMES (as applicable): Name _____________________________________
Title _______________________________
Name _____________________________________
Title _______________________________
FEDERAL ID # _______________________ SUBJECT TO STATE SALES TAX:
Yes ___
SOCIAL SECURITY # _____________________________ No ___
(If No, please supply exemption certificate)
BANK REFERENCE: _______________________________ ACCOUNT NUMBER: ________________ CREDIT REFERENCES (Outside the Optical Industry): 1)
Name _________________________ Address ___________________________________ Telephone (_______) ______________________
2)
Name _________________________ Address ___________________________________ Telephone (_______) ______________________
AUTHORIZED BUYER ______________________ DATE BUSINESS ESTABLISHED: ______________ AT PRESENT ADDRESS SINCE __________________________ NUMBER OF STORES ____________ The above information is complete and accurate and has been provided so that you may rely on it for the purpose of extending credit. This authorizes the release of credit information on my account to Marchon Eyewear, or their authorized credit agencies. DATE: __________________________ SIGNATURE: _________________________________________ SALES REP: _____________________ NAME & TITLE: ______________________________________ DO NOT WRITE BELOW THIS LINE – FOR COMPANY USE ONLY A/C# __________ RX ______ STK ______ LC ____ DATE ___________ REGION _____________