Preferred Select Buying Group Membership Application
Account Information


Account Name
Shipping Address
City
State
Zip

Billing Address
City
State
Zip
Phone
Fax
E-Mail

Type of Business
Partnership
Corporation
Proprietorship

State of Incorporation or Partnership
Date Established
Federal Tax ID Number



Principle Owner


Name
Title
Home Address
S.S.#
City
StateZip

Name
Title
Home Address
S.S.#
City
StateZip

Name
Title
Home Address
S.S.#
City
StateZip



Preferred Select Buying Group Terms and Policies