AChatila CUSTOMER APPLICATION

A. CHATILA
WHOLESALE CUSTOMER APPLICATION

*Please fax application to: 718-227-7601*
Proprietor _____________________________
Company Name _____________________________
Address ____________________________________
City_____________________________ State _________ Zip _________
Contact Name: _____________________________
Years in Business: _____________________________
Type of Business:_____________________________
Telephone# ______________________ Fax #___________________
E-mail Address: _____________________________
*If you prefer terms, please fill out the following credit information:*
Please list 3 Businesses that you already have established credit with (include Name, Address, Telephone and Account Number.)
1.	Name ___________________________________
	Address _________________________________
	City ____________________ State __________ Zip __________
	Telephone Number _____________________________________
	Account Number _____________________________________
2.	Name ___________________________________
	Address _________________________________
	City ____________________ State __________ Zip __________
	Telephone Number _____________________________________
	Account Number _____________________________________
3.	Name ___________________________________
	Address _________________________________
	City ____________________ State __________ Zip __________
	Telephone Number _____________________________________
	Account Number _____________________________________
PLEASE LIST BANK INFORMATION:
Name ___________________________________
Address _________________________________
City ____________________ State __________ Zip __________
Contact Name: ___________________________________

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