Karen Amadio Gates

óFolk Art Designsó

Miniature Punchneedle Embroidery

5251 Downs Run

Pipersville, PA 18947

215-766-0746

Email: Karen@karengatesfolkart.com
Website: www.karengatesfolkart.com

BUSINESS INFORMATION:

(All new accounts must supply the following information—on top of this form whether or not credit terms are desired).

BUSINESS NAME: ___________________________________ PHONE _____________________

ADDRESS: _________________________________________________________________________

___________________________________________ FAX: ___________________________

RESALE TAX ID# ________________________________ EMAIL: __________________________

OWNER’S NAME(S) ________________________________________________________________

HOME ADDRESS(ES) ______________________________________________________________

OWNER’S HOME PHONE: __________________________________________________________

TYPE OF BUSINESS/TYPE OF MERCHANDISE SOLD: _________________________________

____________________________________________________________________________________

YEARS IN BUSINESS: _________________________________

IS THIS BUSINESS OPEN YEAR ROUND? _______YES _______NO

IF NOT, PLEASE GIVE APPROXIMATE SCHEDULE: _________________________________

PAYMENT TERMS DESIRED: _____NET 30(fill out below) _____COD

MC / VISA / DISCOVER # ____________________________________________ EXP: _________ 3-4 DIGIT CVV# _________

REFERENCES FOR CREDIT –TERMS NET 30

Please supply four business references if terms of Net 30 are desired. COD, credit card or prepayment required on all first time orders.

NAME:_______________________________________

ADDRESS:____________________________________

______________________________________________

PHONE: ______________________________________

ACCT#_______________________________________

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NAME:_______________________________________

ADDRESS:____________________________________

______________________________________________

PHONE: ______________________________________

ACCT#_______________________________________

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NAME:_______________________________________

ADDRESS:____________________________________

______________________________________________

PHONE: ______________________________________

ACCT#_______________________________________

BANK NAME: _________________________________ CONTACT: _________________________

ADDRESS: _________________________________________________________________________

PHONE:__________________________________ BUS ACCT #______________________________

I give Karen A. Gates permission to research my business credit including my bank if necessary.

SIGNED (Owner’s Name) : ______________________________

PRINT NAME: _________________________________________ DATE: _______________________