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RETAILER APPLICATION

Welcome to Import Direct Furniture online registration page.
To become our Dealer please follow the steps below.

1, Complete the Registration Form below;
2, Fax a copy of your original Seller's Permit and Business License to Import Direct Furniture at 626-236-5485, Attn: New Accounts Dept.;

Thank you! You will be contacted via email upon complete review of your information.

Applicant Information

Date:
(eg.06/28/1982)

Location:
*

Applicant First Name:
*

Applicant Last Name:
*

Applicant Title:

Company/Shop:
*

DBA:

Company Address:
*

City:
*

State:
*

Zip Code:
*

Country:

Tel:
*

Fax:

E-mail:
*

Type of Organization:
CorporationPartnershipProprietorship

Main Business:
*

Period:

Sales Permit No:
*

Principal Owner/Officer Information

Principal Owner/Officer Name:	Social Security Number:
Home Address:
City:	State:
Zip:	Country:
Phone:	Fax:

Bank References

Bank Name:	Account Number:
Address:
City:	State:
Zip:	Country:
Phone:	Fax:

Trade References

Company Name:	Account Number:
Address:
City:	State:
Zip:	Country:
Contact for Accounts Payable:	Contact Email Address:
Contact Name:	Fax:

Terms & Conditions

This statement has been carefully read by you (the undersigned) an, is your knowledge that the information provided is in all aspects, current, complete, accurate, and truthful. By checking the box below, and providing your authorized signature; you give us authorization to verify your information listed above.

*An authorized password will be sent by email to you upon completion of verification process.*

I Accept

Authorized Signature:

Title:

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