To Become a Retailer

IBIZ Application to be a Retailer

Please make sure to fill out the form below in its entirety. Thank you.

Application for Business Account

Name*

First

Last
Title*
Company Name*
FEIN#*
Date of Commencement*

Date Format: DD slash MM slash YYYY
Registered Company Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country
Phone*
FAX
EMAIL*
Website
Please Indicate IF You are A :*
- Wholesaler
- Distributor
- Retailer
- Broker
Trade References (provide 2 references)
Company Name*

First
Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country
Phone
Email
Type of Account
Company Name

First
Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country
Phone
Email
Type of Account
Agreement
- Prepay all invoice promptly
- Not sell on any deal sites (i.e: Amazon, Ebay, Groupon, Deal Chicken etc)
- Report any changes of the above listed information immediately
- I will not misrepresent IBIZ, Inc or brand in anyway
Signature*
Print Your Name :

First

Last
Date*

Date Format: MM slash DD slash YYYY
CAPTCHA

Trade References (provide 2 references)