Become a Dealer

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Step 1 of 5

Company Info

Company Name * Please enter Company Name

Billing Address * Please enter Billing Address

City * Please enter City

State * Please enter State

Zip * Please enter Zip

Shipping Address *

Same as Billing

Please enter Shipping Address

City * Please enter City

State * Please enter State

Zip * Please enter Zip

Phone Number * Please enter a valid phone number

Fax Number Please enter a valid fax number

Step 2 of 5

Shipping

The following persons are authorized to purchase from this account:

First Name *

1.

Please enter First Name

Last Name * Please enter Last Name

Title Please enter Title

NAME AND TELEPHONE OF PERSON RESPONSIBLE FOR ACCOUNTS PAYABLE:

Name * Please enter Name

Phone Number * Please enter a valid phone number

Fax Number Please enter a valid fax number

Email * Please enter Email

Step 3 of 5

Bank Reference

Would you like to request credit from Emerald Supply?

No

Yes

Step 4 of 5

Trade Reference

1. Company Name * Please enter Name

Account # Please enter Title

Phone Number * Please enter a valid phone number

Email Please enter a valid fax number

Address Please enter Address

City Please enter City

State Please enter State

Zip Please enter Zip

2. Supplier Name Please enter Name

Account # Please enter Title

Phone Number Please enter a valid phone number

Email Please enter a valid fax number

Address Please enter Address

City Please enter City

State Please enter State

Zip Please enter Zip

Step 5 of 5

Reseller Certificate & Signature

STATE SALES TAX EXEMPT:

No

Yes

If yes, you must provide Emerald Supply with a copy of your tax exemption certificate to avoid being charged sales tax.

Reseller Certificate

This information is warranted to be true and is given for the purpose of obtaining credit from Emerald Supply. I (we) agree to pay all bills for purchases net 30 days from the date of invoice. Should legal action be instituted to enforce payment of any outstanding balance, I (we) agree to pay all costs of suit and reasonable attorney’s fees.

Signature

Print Name & Title * Please enter Name

Thank you, we will contact you as soon as possible.

Have a Question?

Send us a message and someone from our sales team will reach out to assist you.

Become a Dealer