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Private Label Application Print E-mail
Your Company Name:
Street Address:
Web Site URL:

State Resale Certificate Number:

Date of issue:
Federal Employer Identification Number:
Name of Accounts Payable Manager:
Company is:
If corporation, what is the date of incorporation?
Years in business?

States in which applicant does business:



Trade References:
1. Name:
2. Name:
3. Name:
4. Name:

New York State Sales Tax Applies

New York State Sales Tax Does Not Apply (Resale Cert. Attaced if applicable)

General Provisions

This application and the information contained herein is a request for the extension of credit for commercial business use only and each applicant certified that the firm he represents is doing business either as a Corporation, Partnership, or Sole Proprietorship. Each applicant authorizes named Creditor to obtain written or verbal credit reports from any credit reporting agency.


Our Terms

NET 30

If credit is extended, I (we) agree to pay creditor all debts incurred within Creditor's terms of sale. I (we) waive all right of exemption under the constitution and laws of any States, as to personal property and I (we) agree to pay ALL COSTS OF COLLECTION or attempting to collect or secure any and all debts which I (we) may in the future owe Creditor for goods sold to me (us). I (we) also agree to pay a FINANCE CHARGE OF 2% PER MONTH (ANNUAL PERCENTAGE OF 24%) on any unpaid past due balance. The Creditor is hereby authorized to deliver goods for the following at my (our) request and charge same to my (our) account and this shall continue until written notice to the contrary if given and accepted by Creditor. I (we) agree to IMMEDIATELY notify TOPAZ of any change in ownership, address or form of said business.


The above information is to be used for the express purpose of being established as a dealer with Topaz Industries.

Thank you for your cooperation.

Signature of Principal:_____________________________ Print Name:

Signature of Principal:_____________________________ Print Name:

Please submit below and forward A SIGNED copy of this information immediately to: Fax (631) 207-0705


Created by Titan Technology, Corp.