Part 1 - Basic Business Information"

Registered Company Name

Registered DBA (if applicable)

Tax Id Number

First Name (owner, principle or president)

Last Name (owner, principle or president)

Email

Registered Address 1

Registered Address 2

Registered Address City

Registered Address State

Registered Address Zip Code

Date Business Commenced

Type of Company
Select Company TypeSole ProprietorshipPartnershipCorporationLLCOther

Invoices are emailed please provide email address

Mailing Address: (if different from above)
Mailing Address 1

Mailing Address 2

Mailing City

Mailing State

Zip Code

Part 2 is Banking Information and Business References:
BANK INFORMATION or submit your prepared document making sure all required information is included.
Bank Name:

Contact Name:

Contact Email:

Phone:

Address:

City:

State:

Zip:

Select Account TypeCheckingSavingsOther
Account number (Last four digits for reference is sufficient)

Upload (.pdf, doc, jpg)
Bank Information prepared document

Company References:
Company Name:

Contact Name:

Contact Email:

Phone:

Address:

City:

State:

Zip:

Company Name:

Contact Name:

Contact Email:

Phone:

Address:

City:

State:

Zip:

Company Name:

Contact Name:

Contact Email:

Phone:

Address:

City:

State:

Zip:

Business References prepared document

TAX EXEMPTION CERTIFICATE(S):
Please provide us with your sales tax exemption certificate(s) for all the state in which you are registered.
Upload (.pdf, doc, jpg)

additional in needed

Should you have any questions, comments or other narrative. please enter below (optional)

Once complete please click Submit below and thank you for choosing Dwell America!

Δ