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austin design
   
WHOLESALE  VERIFICATION  FORM
Password & Wholesale Catalog Request
If you are a wholesale buyer and wish to view our jewelry online or wish to receive our full color catalog, we do require that you verify your wholesale status.  This is necessary before passwords are issued, wholesale catalogs are released, or any orders are processed.  If you prefer, you may print this form and then fax or mail the information.
   


CONTACT  INFORMATION
   
Store Name: Store Phone:
   * *   
   
Contact/Buyer's Name: Store Fax: 
   *
   
Owner's Name (if different from above) E-Mail Address:
*   
   
Store Address:  (actual physical location of your store) Shipping Address (if different):
   *
   
      *  City City   
* State  * Zip State Zip 
          *   Country / Area Country/Area        
   
MAILING  &  ACCOUNTS  PAYABLE
 
Do you have a separate office for Accounts Payable & Catalog Mailings?     (If  "YES",  please enter information below)
 
Office Mailing Address  (leave blank if not applicable):
 
Office City:        Office State:        Office Zip:   
 
Office Phone:        Office Fax:         
 
STORE  BUSINESS  DETAILS
 
* Type of business:                If "other" please specify:  
 
* Retail Re-sale License #  (a.k.a. State Tax I.D. Number):           (required)
 
* Location of Store:                   If "other" please specify:  
 
* Type of Store:                        If "other" please specify:  
 
* Types of Merchandise sold:
 
* Hours & Days of Operation:                  * Years in Business:   
   Tell us a little about your store, clientele, and merchandise; mention any details which will help us serve you better:
WHOLESALE  TRADE  REFERENCES
 
(1)    Vendor:        Account #:         
         Phone:                      Fax:         
 
(2)    Vendor:        Account #:         
         Phone:                      Fax:         
 
(3)    Vendor:        Account #:         
         Phone:                      Fax:         
 
(4)    Vendor:        Account #:         
         Phone:                      Fax:         
 
(5)    Vendor:        Account #:         
         Phone:                      Fax:         
TERMS  &  CONDITIONS
 
I/We agree & certify that all the information provided on this form to Austin Design Jewelry Inc. is true and correct. I/We guarantee all payments of debt when due, for every invoice or claim when due that may arise in the course of our continuing business relationship with Austin Design Jewelry Inc. I/We agree to pay the total amount due, including any late fees, returned check fees, court costs, attorney fees and any other fees incurred in the collection of unpaid invoices.
 
* I have read & agree to the above terms and conditions.    
 
          


Our Response
Upon verification (usually 1 or 2 business days) we will email you a password
and mail you a full color catalog and price list.

Confidentiality
We do not sell, trade, or share our mailing lists or client information. Any information submitted is kept in strict confidence.
If at any time you would like to be removed from our files, simply contact us. Filling out this information
carries no obligation whatsoever. And we do not practice any phone or e-mail solicitation!

Problem?
Having trouble submitting this form? Don't forget that fields marked with * are required.
If you would prefer to have a print version of this form, click here, and fax to 434-832-7090.
 
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