Send 123 - client Application Form

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Contact Information:

Owners Name*

Owners Email*

Company Phone Number*

Company Legal Name*

DBA Name*

Website URL*

Company Contact*

Company Contact Email*

Company Contact Phone Number*

LinkedIn Profile

Business Address*

Do you currently have a D-U-N-S# (Dun and Bradstreet)?* Yes No

If Yes, please provide the D-U-N-S #

Time in Business

Your Current Purchase Order Value*

Current Payment Terms with Your Customer*

Product Being Sold*

Your Margin on Product (%)*

Location of Supplier

Location of Customer

Deposit on Order*

Currency*

USD CAD Yen

Number of days to pay supplier*

How many days in delivery from supplier final payment until your client receives the goods?*

How many days from delivery day until your client pays you?*

Are you working with a broker?*

Upload Logotype or Principal Image*

Choose a local file

If Yes, please add Brokers ID number and name