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Please complete this application form to set up an account with Oenophilia. All fields marked with an asterisk (*) are required fields.

Contact Information
*User Name:
*Password:
*Confirm Password:
*Company:
*Buyer First Name:
*Buyer Last Name:
*Email:
*Phone:
Fax:
Billing Address
*Accounts Payable Contact:
*Address:
2nd Line:
*City:
*State:
*Zip:
Shipping Address
Same as Billing Address
*Address:
*2nd Line:
*City:
* State:
*Zip:
Bank Information
*Bank Name:
*Account #:
*Officer Contact:
*Address:
2nd Line:
*City:
*State:
*Zip:
*Phone:
Fax:
Miscellaneous Information
*Federal Tax ID #:
NC Sales Tax #:
*Years In Business:
*Number of Employees:
Dunn & Bradstreet #:
Revenue:
*Credit Limit Requested:
* if over $500, FAX us a D&B or Financial Statement.
Our Terms are NET 30, Do you agree to pay by these terms?
Yes, I agree to NET 30 terms.*
Trade References
*Reference 1 Name:
*Phone:
Fax:
*Account #:
*Reference 2 Name:
*Phone:
Fax:
*Account #:
*Reference 3 Name:
*Phone:
Fax:
*Account #:
Remarks
Any Remarks?:
I have read the policies and agree to the terms as outlined above.
*Authorized Buyer Name:
*Title:

 
 
 
 
 

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