WHOLESALE ACCOUNT APPLICATION FORM

Victory USA LLC DBA Got Pods for Zlab Pods.

To set-up a wholesale account, please fill in the information below and fax or email the
form back to us. If you have any questions, please call us at (516) 225-2069

Fax – 877-765-2698 Email – justpodsusa@gmail.com

Company Info:

Company Name: _____________________________________________

Billing Address: _____________________________________________

Postal Code/Zip Code: _____________________________________________

City and State _________________ ___________________

Shipping Address: _____________________________________________

Postal Code/Zip Code: _____________________________________________

City and State _________________ ___________________

Federal Tax ID number: _____________________________

Contact Details:

Contact Name: ________________________________________

Phone Number: (___) ____-_____

Email Address : _______________________________________

(Your Business name) _________________________________ is responsible for paying

all State/County Tobacco excise Taxes.

Owner’s Signature : ________________________________ Date :_________

Credit Card Info:

Name on a Card: _________________________________

Credit Card Type (Visa, M/C or Other): ____________________________

Credit Card Number: ______________________________________

Expiry: ______________________________________

Security Code: ________________________________________

Signature: _______________________________________

By signing this form, I give permission to Victory USA LLC. DBA Got Pods to charge
my credit card for any shipments or overdue invoices.

*Attached a copy of Federal Tax ID with your application.*