Billing Address:
Account Name:       Phone:
Address:   Fax:
Address 2:   State:
City:   Zip:
Country:  
 
Contact Information:

Email:

Name of Person to Contact for Payment:

First Name:      Last Name:
Authorized Purchaser:
First Name: Last Name:
 
Complete Shipping Address:(if different)
Address 1:
Address 2:      State:
City:   Zip:
Country:  
Type: Commercial: Residential: Rural
 
Credit Information:
Date Business Established      Sales Tax #:
 
Check One:
Corporation:      Partnership:      Proprietorship:
Federal ID Number:   # of Partners:   SSN:

Check One:
Credit Limit Desired:   $        C.O.D       Open Account
 
Company Officers:
Principals Names:      Title:
Residence Address: Residence Phone:
City: Zip:
Principals Names: Title:
Residence Address: Residence Phone:
City: Zip:
Principals Names: Title:
Residence Address: Residence Phone:
City: Zip:
 
Marine Trade References:
Names:      Account Number:
Address:   Phone:
City:   Zip:
Names:   Account Number:
Address:   Phone:
City:   Zip:
Names:   Account Number:
Address:   Phone:
City:   Zip:
 
Bank References:
Bank Names:      Account Number:
Address:   Phone:
City:   Zip:
Bank Names:   Account Number:
Address:   Phone:
City:   Zip:
 
Customer Type:(Check One)
Stocking Dealer w/store
Stocking Dealer/no B&M(include hardware,tackle,sporting goods,ect.)
Boat Yard w/store
Boat Yard no store
Marine Service w/storefront
Marine Service /storefront
Manufacturers OEM (boat builders only)
Exporters (licensed by US to sell and ship goods outside continental limits of US).
Government
(explain):
Other
(please give details; include distributors,OEM's other than boat builders,chains etc.):
 
General Information:

1. Do you plan to maintain an inventory of the items you are interested in?
Yes No

2. For what purposes will JMS merchandise be used
3. Forecast of annual Purchases:

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