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Prospective Wholesale Customer Application If you're interested in opening a wholesale account with us, kindly fill out the form below or e-mail us at info@kurtadler.com to request an application by fax or mail. Business references may be contacted before access to on-line ordering is authorized. Your first order must be by credit card. Different credit terms may be available after your first order. Once you have been authorized for on-line ordering, you will receive an e-mail at the address you provide below. All fields with an asterisk (*) are required. *Company Name: *Resale Number: *Type of Business: *Contact First Name: *Contact Last Name: *Address Line 1: Address Line 2: *City: *State/Province: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Nova Scotia Newfoundland N.W.T. Ontario Quebec Prince Edward Island Saskatchewan Yukon Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau Other *Zip/Postal Code: *Country: Argentina Australia Austria Belgium Brazil Canada Caribbean Chile China Colombia Czech Republic Denmark Europe Finland France Germany Hong Kong Hungary India Ireland Israel Italy Japan Korea Latin America Luxemburg Malaysia Mexico Middle East Netherlands New Zealand North Africa Norway Peru Poland Portugal Russia Singapore Slovakia Slovenija South Africa Spain Sweden Switzerland Taiwan Thailand Turkey United Kingdom United States Uruguay Venezuela Other *Phone Number: Fax Number: *E-mail Address: Website Address: Three Business References are required: Reference #1: *Name of Company: Contact Name: *Telephone Number: *Account Number: Reference #2: *Name of Company: Contact Name: *Telephone Number: *Account Number: Reference #3: *Name of Company: Contact Name: *Telephone Number: *Account Number:

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