Wholesale and Credit Application
Elizabeth Rose Purity Inc. 137 South Searsville Road Montgomery, New York 12549 phone: (877) 457-7627  fax: (845) 457-9802 Email: kquick@elizabethrosesoaps.com		PRINT & FAX

Please fill out this application as completely as you can.   Please submit the completed application, either by clicking on the SUBMIT button below or Print and send by Fax.  Once we receive your application, and check your references, we will notify you via email that your password has been activated. Once you receive this notification, you will be able to place your first wholesale order, by going through the Wholesale Login page. Please note that you cannot place a wholesale order until you have received an email confirmation from us. You will not be able to access the wholesale ordering page until after that email confirmation.
Business Name:
Legal Name (if different):
State Tax Resale#:
Issue State:
Kind of Business:
Years in Business:
Type of Business:	Health Food Store SPA - Hair Salon Gift Shop Other
BILLING INFORMATION
Address:
Phone:
Fax:
Email:
Accounts Payable Contact:
Special Billing Instructions:
Wholesale Log In Information:
Username :
Password:
PLEASE GIVE US TWO TRADE REFERENCES
Company:
Address:
Phone #:
Contact Person:
Company:
Address:
Phone #:
Contact Person:
The requested information is provided for the purpose of opening an account and for obtaining credit. The undersigned authorizes Elizabeth Rose Purity, Inc. to make inquiries as are necessary to obtain credit information and certifies the information in this application are true and correct.   The undersigned attests financial responsibility and willingness to pay invoices within the terms established by Elizabeth Rose Purity, Inc.  It is understood that all past due invoices will be subject to a 1.5% monthly finance charge if not paid by due date and any past due accounts sent to collections may incur additional fees.   In the event this account becomes delinquent, all written and verbal communications will be an attempt to collect the debt and any information will be used for that purpose.
Type Name:
Title:
Date: