Section 1 - Contact Information:
First Name:
*
Last Name:
*
Title:
*
Entity:
Corporation
Partnership
Sole Proprietorship
Other
*
If Other, please Explain:
email Address:
*
Company Phone:
*
Company Fax:
Company Web Site:
*
Section 2 - Billing Information:
Billing Address:
*
Billing Address:
City:
*
State:
*
Zip/Postal Code:
*
Country:
*
Section 3 - Shipping Information: (Leave blank if same as billing)
Shipping Address:
Shipping Address:
City:
State:
Zip/Postal Code:
Country:
Section 4 - Company Information:
Type of Business:
Retail Gift
Retail Dive
Retail Outdoors
Retail Fishing
Retail Other Specialty
Online Dive
Online Gift
Online Outdoors
Online Fishing
Online Other Specialty
Charitable Organization/Fundraising
Special Event Planner
*
How Many Employees:
1
2
3-5
6-10
11-20
Over 20
*
Business Days (Check all that apply):
Hours Open:
Date Business Opened:
*
Approximate Annual Purchases of Wearables:
Under $5000
$5000 - $10,000
$10,001 - $50,000
Over $50,001
*
Insurance:
All Shipments are Insured
Method of Payment:
Visa
MasterCard
American Express
*
Section 5 - Sales Tax:
We are required by the State of Florida to collect sales tax
for shipments delivered within the state, unless we have a valid
resale certificate number on file.State of Florida and you
do not wish to be charged sales tax, please enter your Florida
Resale Certificate Information.
Certificate Number:
Expiry Date:
(Note: Sales tax will be charged on all orders
until we receive copy by fax of your Resale Certificate and we
are unable to retroactively credit back the sales tax. Please
fax asap to 305.293.0920.)
Section 6 - Agreement:
I would like to:
Purchase Online
Purchase by Phone
Purchase in Person
*
Names and titles of those authorized to make
purchases for your company?
Name & Title:
Name & Title:
Name & Title:
Name & Title:
Electronic signature: By checking
below and typing my name, I agree that I am authorized to
complete this application for the company, am a valid retailer
and that the above persons are authorized by me to make
purchases on behalf of our company. I hold Island Image harmless for any abuse of our purchasing powers or errors
by our employees. If I have checked above that I will be using
credit card, by checking below and typing my name, I agree to
pay all subsequent credit card charges incurred by myself or my
employees at my authorization, according to card issuer
agreement.
I have read and understand the agreement:
*
Type your legal name and company title:
*
