| Section 1 - Contact Information: |
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First Name:
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Last Name:
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Title:
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Entity:
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If Other, please Explain:
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email Address:
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Company Phone:
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Company Fax:
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Company Web Site:
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| Section 2 - Billing Information: |
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Billing Address:
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Billing Address:
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City:
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* |
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State:
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* |
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Zip/Postal Code:
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* |
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Country:
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* |
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| Section 3 - Shipping Information: |
(Leave blank if same as billing) |
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Shipping Address:
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Shipping Address:
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City:
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State:
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Zip/Postal Code:
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Country:
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| Section 4 - Company Information: |
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Type of Business:
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How Many Employees:
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* |
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Business Days (Check all that apply):
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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Hours Open:
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Date Business Opened:
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* |
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Approximate Annual Purchases of Wearables:
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* |
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Insurance:
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All Shipments are Insured |
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Method of Payment:
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* |
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Section 5 - Sales Tax:
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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.
If your business is in State of Florida and you
do not wish to be charged sales tax, please enter your Florida
Resale Certificate Information.
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Certificate Number:
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Expiry Date:
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| (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.) |
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| Section 6 - Agreement: |
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I would like to:
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* |
| Names and titles of those authorized to make
purchases for your company? |
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Name & Title:
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Name & Title:
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Name & Title:
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Name & Title:
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| 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. |
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I have read and understand the agreement:
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(Must Check Box) * |
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Type your legal name and company title:
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* |
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or |