NAME ____________________________________________________
COMPANY NAME ____________________________________________
ADDRESS _________________________________________________
_________________________________________________
IS THIS BUSINESS A CORPORATION? _________________________
DATE BUSINESS ESTABLISHED _______________________________
LIST OF PRINCIPALS WITH PERCENTAGE OF OWNERSHIP (INCLUDE
NAME, ADDRESS, HOME PHONE, SOCIAL INSURANCE # AND ATTACH
A PHOTOCOPY OF CURRENT, VALID DRIVER'S LICENSE)
_________________________________________________________
_________________________________________________________
_________________________________________________________
HAVE THERE BEEN ANY CHANGES OF OWNERSHIP? IF SO, DESCRIBE
_________________________________________________________
E-MAIL ADDRESS __________________________________________
SYSTEM USERNAME(S) ______________________________________
DAY-TIME, M-F PHONE NUMBER ______________________________
FAX NUMBER ______________________________________________
NUMBER OF YEARS IN BUSINESS __________
PRINCIPAL LINES OF BUSINESS _____________________________
INDUSTRY MEMBERSHIP(S) AND MEMBERSHIP NUMBER(S)
_________________________________________________________
_________________________________________________________
BUSINESS REFERENCES (Please provide at least five that you
have dealt with for a minimum of three years)
1) ______________________________________________________
2) ______________________________________________________
3) ______________________________________________________
4) ______________________________________________________
5) ______________________________________________________
BANKING REFERENCES AND CONTACT NAMES
1) ______________________________________________________
2) ______________________________________________________
I hereby authorize all the above listed parties to provide
Collectible-Trade.com with reference information
regarding my/our business.