Wholesale Application
 

Company Name:

Business Type:

  Provide business details including years in business
Intend to resell:

Check all that applies:

Dental Caps/Grills

Custom Jewelry (Pendant, Chain, Bracelet, Earrings, etc.

Watches

Jewelry and Watch repair (includes rhodium, polishing, etc)

 

 
First Name Name:
Last/Family Name::
Billing/Shipping Address :

City:
State:
Zip/Postal Code:
Phone Number:
Fax Number:
Email Address:  
Payment Type CHECK ONE:

VISAMasterCard American ExpressDiscover

Money Order Paypal
Credit Card Number:   
Credit Card Expiration :   example: 02/08
CVV (Security) Code:   3 digits from back of card or 4 digits from front if AmEx
 

Signature:

 By signing below I agree to abide by Johnny Dang & CO DBA TV Jewelry's Wholesale Terms and Conditions.  .                                                                           

 
Date:

Press Ctrl + P keys in your keyboard to print completed form.