Andrew Dutton Inc. :: Avon MA

Application For Wholesale Account

If you are an existing customer please fill out this form here

Contact Information
Contact Name:
Phone:
* Email:		required
Fax:
Dept:
Best time to call:
Company Address
Company Name:
Corporation Partnership Individual
Address:
City:
State:
Zip:
Shipping Address if Different:
Billing Instructions (Person/Dept):

Sales Tax Status
For Resale :		#
Exempt Institution :		#

Payment Terms
Cash (payment in full)
C.O.D.
Credit Card:		we will call you to collect credit card information
Trade Account (Net 30 days)		please complete application below

Trade Account Information
Banking Information
		We will call you to get your account infomation and banking account information. Please have this available.

Trade References
1. Name:
Account # :
Address:
Phone:
Email:
Fax:

2. Name:
Account # :
Address:
Phone:
Email:
Fax:

3. Name:
Account # :
Address:
Phone:
Email:
Fax:

4. Name:
Account # :
Address:
Phone:
Email:
Fax:


Company Name:
Title:
Name (as signiture):