200 Liberty St

RT Metuchen, NJ 08840
Phone: 732.603.7346 | Fax: 732.603.7348
Contact@ReGoTrading.com
ReGo Trading
Wholesale Distributor

NEW ACCOUNTS APPLICATION

COMPANY BILLING
Company Name Type of Business:
Contact Name  Sole proprietorship  Partnership
Email Address  Corporation  Franchise
Phone Number  Other _____________________
Fax Number
Registered Company Nature of Business:
Address, City, State, ZIP  Wholesale  Pharmacy
Years in Business?  Retail  Chain
Years at Present Location?  Online Retailer  Supermarket
Federal Tax-ID  Other _____________________
COMPANY SHIPPING
Facility/ Company Name Receiving Name
Receiving Company Primary Phone Number
Address, City, State, ZIP Secondary Phone Number
Email Address Fax

OWNERS/ PRINCIPALS/ ACCOUNTS PAYABLE IN COMPANY

I I

Full Name Title Phone Email

SIGNATURES
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Signature Signature
Name and Title Name and Title
Date Date

You MUST attach your resale certificate with this new accounts application
**If you do not attach your resale certificate, your account will not be processed**