Picky Bars - Account Application

Company Name *
Contact Name *

First Name Last Name
Contact Position *
Store Phone Number *

Area Code Phone Number
E-mail *
Website *
No Online Sales *

I understand that I cannot sell Picky Bars online without prior approval.
How Did You Hear About Us?
Sales rep, magazine article, online, etc.
Billing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Shipping Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Buyer Name *

First Name Last Name
Buyer Number *

Area Code Phone Number
Finance Name *

First Name Last Name
Finance Number *

Area Code Phone Number
Retail Tax ID# *
Payment Method *

Credit Card Terms (Opening order will be placed on a Credit Card)
* Please note that Picky Bars will contact you for Credit Card information prior to the first shipment!
Signature *
Date *
Should be Empty: