Complete attached .DOC file and email to: suzie.hagerty@blucollarmusic.com
Store information:
Store Name: _________________________________________________
Address: ____________________________________________________
Address: ____________________________________________________
City:_________________________________State_______Zip _________
Phone: (___) __________-________________Extension#______________
Ship to: ❐ same
Name: _____________________________________________________
Address: ____________________________________________________
Address: ____________________________________________________
City:___________________________State_______Zip _______________
Fax # ❐ same as phone: (___) _________-____________________________
E mail ____________________________ @ ________________________
Website: _____________________________________________________
Authorized for Purchasing: ____________________________________
First Name ___________________Last Name_________________________
Phone (_________) _____________________________________________
Bank References: Name on Account ❐ same ____________________________________________________________
Bank_________________________________________________________
Address or Branch _______________________________________________
Business License or Resale License
(IMPORTANT: California requires a signed Tax Exemption Certificate and must be on file prior to shipping orders)
State:____________ ID#_________________________________________
Type of Store: check all that apply: ❐ Retail Music Store ❐ Pawn & Music ❐ Internet Sales Only ❐ Internet and Retail Products/Services offered: ❐ Fretted Instruments/ Amplifiers ❐ Drums/Percussion ❐ Band/Orchestra ❐ Print Music ❐ Repairs
❐ Recording Studio ❐ Keyboard/Piano/Organ ❐ Teaching Studio ❐ Spanish/Hispanic Market or Customer Base ❐ Other_____________
Store Hours: ❐ Monday to Friday from______to _______ Closed_________
Do you give lessons? ❐ Yes ❐ No
Instruments Taught: ❐ Guitar ❐ Banjo ❐ Mandolin ❐ Drums Number of Instructors: ____
Lines carried:_______________________, ___________________________.
______________________, ______________________,_______________
*I hereby certify the above information is correct and authorize above references to release any and all information concerning my account.
Print Name:___________________________________________
Signature __________________________________________Date __/___/___
Shipping: ❐ UPS ❐ other _____________
Terms: ❐ Bank Card (Visa, MC or Discover)
❐ COD Company Check (bank info required for COD)
Trade References:
Application Received Date: ____/___/__ ❐ References Checked
❐ Cat/Flyer Sent _____/_____
❐ Contacted by _____ Order Placed: ___/___/___
Account Number:_____________Date Entered: ____/____/____
Account assigned to:_________________
Notes:_________________________________________________________
______________________________________________________________