Jackson Pottery

Wholesale Customer Registration:

CUSTOMER INFORMATION:

Company Name:

DBA/Alternate Company Name:

Type of Business:

Business Website:

Tax ID#:

Buyer’s Name:

Buyer’s Phone Number:

Business Phone Number:

Buyer’s Email:

Ship To Address:

Building/Suite:

City:

State:

Zip:

Does the Ship To address have:

Forklift:

Yes
No

Dock:

Yes
No

Pallet Jack:

Yes
No

Ship To Address:

Business
Residence

Is the address 18-wheeler accessible?:

Yes
No

Receiving Days:

Receiving Hours:

Receiver’s Name:

Receiver’s Phone Number:

Receiver’s Email:

PAYMENT & BILLING INFORMATION:

Do you work with a distributor? If yes, please choose one:

Arett Sales
BFG
BWI
Foster’s
Wyatt Quarles

(If billing through a distributor, payment and billing info is not applicable):

Bill To and Ship To Address the same?:

Yes
No

Bill To Address:

Building/Suite:

City:

State:

Zip:

AP Contact Name:

AP Phone Number:

AP Email:

Credit card on file required for all accounts. (NA for distributor customers) :

Card Type:

American Express
Discover
Mastercard
Visa

Card Number:

Exp:

CVV:

Name on Card:

Billing Zip: