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New Dealer Credit Application

New Dealer Credit Application

Please fill out the form below or download the PDF and fax it to us at 972-233-3364 or email it back to us at sales@shopagi.com.

Store Information

Date *

FOR THE PURPOSE OF OBTAINING MERCHANDISE FROM AUTHENTIC GEM IMPORTS, INC. ON CREDIT, WE SUBMIT THE FOLLOWING INFORMATION AND AUTHORIZE YOU TO CONTACT THE REFERENCES GIVEN.

Firm Name *
Street Address *
City *

State *
Zip Code *

Country
Phone Number *

Fax Number
Email *
Type of Business *
- Corporation
- Partnership
- Proprietorship
- Other
In Business Since (Year) *

At Present Location Since (Year) *
Tax ID *

JBT ID Number *

Security, Insurance and Bank Information

Insured By *

Contact Person *
Phone Number *

Alarm System
Safe Type and Rating

Bank Name *
Bank Street Address

City
State

Zip Code
Country

Bank Officer
Phone Number *

Account Number *

Store Owner

Owner First Name *

Last Name *
Home Street Address *
City *

State *
Zip Code *

Country
Phone Number *

Social Security Number
Driver License Number

Authorization

Resale Certificate Number *

Title

Owner or Officer Only
IT IS UNDERSTOOD AND AGREED THAT PAYMENTS RECEIVED BEYOND THE TERMS STATED ON OUR INVOICES WILL BE SUBJECT TO LATE CHARGES. AS A FURTHER INDUCEMENT TO EXTEND CREDIT, I/WE AGREE THAT IN THE EVENT A SUIT IS BROUGHT ON ANY OBLIGATION HEREAFTER OWED BY ME/US *
- I agree to the Terms.
Authorized by *

Authorized Signature *

Signature
I, hereby personally guarantee the obligation of the above applicant. *

Agreement Signature

Credit/Trade Reference #1

Company Name #1 *
Company Contact/Title *
Address *
City *

State *
Zip Code *

Country
Phone Number *

Fax Number
Email *
Number of years doing business *
Highest Credit ($) *

Credit/Trade Reference #2

Company Name #2 *
Company Contact/Title *
Address *
City *

State *
Zip Code *

Country
Fax Number

Email *
Number of years doing business *

Highest Credit ($) *

Credit/Trade Reference #3

Company Name #3 *

Company Contact/Title *
Address *
City *

Zip Code *
State *

Country
Phone Number *

Fax Number
Email *

Number of years doing business *
Highest Credit ($) *

* Required Fields

PHONE

EMAIL

VISIT US

SHIPPING AND MEMO POLICY

New Dealer Credit Application

Store Information

Security, Insurance and Bank Information

Store Owner

Authorization

Credit/Trade Reference #1

Credit/Trade Reference #2

Credit/Trade Reference #3

PRODUCTS

SERVICES

OUR COMPANY

PHONE

EMAIL

VISIT US

SHIPPING AND MEMO POLICY

Registered Customers

Retrieve your password here

New Customers

New Dealer Credit Application

Store Information

Security, Insurance and Bank Information

Store Owner

Authorization

Credit/Trade Reference #1

Credit/Trade Reference #2

Credit/Trade Reference #3

PRODUCTS

SERVICES

OUR COMPANY