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WHOLESALE APPLICATION
WHOLESALE APPLICATIONS WILL NOT BE PROCESSED COMPLETED IN FULL, AGREED, AND DATED.

BILL TO: SHIP TO: (Same as billing information)
* FIRST NAME * FIRST NAME
* LAST NAME * LAST NAME
* COMPANY * COMPANY
* STREET ADDRESS * STREET ADDRESS
* CITY * CITY
* STATE * STATE
* COUNTRY * COUNTRY
* ZIP CODE * ZIP CODE
* PHONE # * PHONE #
* EMAIL ADDRESS
TYPE OF ORGANIZATION (*)
CORP. WHOLESALER RETAILER INDIVIDUAL OTHER
RESALES CERTIFICATE # / E.I.N. # :
Field denoted by an asterisk (*) are required.
I hereby certify that the above statements are true and correct to the best of my knowledge. I understand that the submission of false information may result in serious charges and that I am fully obligated in legal actions brought against me by Elim Jewelry Corp. I authorize Elim Jewelry, Corp. to process any and all charges outlined in existing agreement. I agree that this authorization shall continue in effect until revoked by me in writing but my obligation to pay is subject to the terms of the Agreement.
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