RETAILER ACCOUNT APPLICATION

Complete this form for application for retailing Village House Importers products. Please be accurate and complete for best processing of application.

Primary Contact

Enter as XXX-XXX-XXXX

Business Information

Enter as XXX-XXX-XXXX
Enter as XXX-XXX-XXXX

Company Address

Shipping Address


Required Contacts

Enter as XXX-XXX-XXXX

Business Interests


Trade References

You may upload trade references in section (A.) or enter your trade references in section (B.).

A. Upload references

B. Enter references

Enter as XXX-XXX-XXXX
Enter as XXX-XXX-XXXX
Enter as XXX-XXX-XXXX

Bank Reference

Enter as XXX-XXX-XXXX

Required Supporting Documentation

1. Upload copy of business license below or fax it to: 817.337.6095

2. If you are an online retailer, upload a copy of your domain name registration or account registration with a web-based retailer (Amazon, etc) below or fax it to: 817.337.6095

3. If you are paying by credit card, please download the Credit Card Authorization form below and fax the
completed form to : 817.337.6095

Alternative text

Disclosures and Acknowledgement

A FINANCE CHARGE OF 1.5% PER MONTH, WHICH IS AN ANNUAL PERCENTAGE RATE OF 18% PER ANNUM, WILL BE CHARGED ON THE UNPAID BALANCE OF PAST DUE ACCOUNTS. THE PURCHASER AGREES TO PAY ANY AND ALL FEES FOR COLLECTIONS, ATTORNEY, AND COURT FEES AFTER DEFAULT AND REFERRAL TO COLLECTIONS OR AN ATTORNEY. VillageHouse Importers, Inc RESERVES THE RIGHT TO TERMINATE ANY ACCOUNT FOR ANY REASON.

By completeing the following fields you are hereby acknowledging the the accurracy of the information in this form and permitting us to verify it.