1
APPLICANT INFORMATION
Name:
Date of Birth: Phone:
Current Address:
City: State: ZIP Code:
BUSINESS INFORMATION
Legal Business Name:
DBA: Established Date:
Phone: E-Mail: Fax:
Website URL:
eBay Store URL:
Federal Tax ID #: (Enter Federal Tax ID and attach copy of the form)
Resale #: (If sales tax exempt, enter resale number and attach copy of exemption certificate)
Business Type (Circle one): Sole Proprietorship Corporation Partnership Individual
Primary Business Address:
City: State: ZIP Code:
Principle Officers: (Name, Title, and Address)
BUSINESS SOCIAL MEDIA
(Fill in handles or URL for all that are applicable)
Twitter: Facebook:
Other:
BUSINESS VENUE OF OPERATIONS
(Fill in all applicable fields)
Brick & Mortar
Store Name: Address:
City: State: ZIP Code:
Store Website URL: Facebook Group URL:
How long have you been at this location?
Online Breaker
(Fill in handle for all that are applicable)
Breaker Company Name:
Website URL: Breakers.TV:
Ustream: YouTube:
Facebook: Other
2
Trade Shows
(List events attended within the last calendar year)
Event Name: City/State:
Event Name: City/State:
Event Name: City/State:
Event Name: City/State:
TRADE REFERENCES
Company Name and Contact: Date of Last Sale: Payment Terms: Total Outstanding Balance:
BANK REFERENCES
Bank Name (#1): Bank Acct #/Type:
Bank Address: Bank City/State/Zip:
Bank Contact: Bank Phone:
Bank Name (#2): Bank Acct #/Type:
Bank Address: Bank City/State/Zip:
Bank Contact: Bank Phone:
SIGNATURE & AUTHORIZATION
The signature below represents and warrants that (a) the party signing below is an authorized representative of the company; and
(b) that the information provided herein is a complete and accurate representation of the company’s legal and financial situation as of
the date hereof. Any misrepresentation or fraudulent information provided will be the basis for default under this agreement. By
signing this form, I expressly authorize All Sports Marketing, Inc to contact the above references to determine credit worthiness.
Signature of applicant Date
Print Name Title
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