Vendors

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Legal Representative/Owner Information

Legal Representative / Owner Name

First Last

Title

ID Number

DOB

Phone

Mobile

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Accounts Receivable Information

Accounts Receivable Contact Name

First Last

Title

Phone

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Billing Information

Name of Person in Charge of Billing

First Last

Phone

Billing Company Name (if different from company name)

Billing Address (if different from company address)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Bank Information

Bank Name

Account Holder Name

Account Number

Confirm Account Number

ABA Routing Number

SWIFT

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Supporting Documents

Attach Photo ID and Supporting Documents

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, Max. file size: 300 MB.

NOTICE

Please attach a valid photo ID of the legal representative/owner.

If you are a company in the United States, please complete and return the Form W-9 with your application.

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Business / Trade References

Reference #1

Company Name

Contact Name

First Last

Phone

Reference #2

Company Name

Contact Name

First Last

Phone

Reference #3

Company Name

Contact Name

First Last

Phone

Confirmation of Information Accuracy and Release of Authority to Verify

I hereby certify that the information provided in this Client/Vendor information form is true and correct. The information provided will be used to determine acceptance of my account with HAIFA WHOLESALE LLC. I understand that all sources of information may also be used in order to determine my new account approval and terms. I hereby authorize the banks, trade references, and other individuals listed above to release any information requested by HAIFA WHOLESALE LLC as needed to assist in the new account approval process.

Name

First Last

Title

Date

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