Dealer Application

*Full Name (Human Applicant)

*Country (USA, Spain, Italy, etc)

*Legal Business Name (Business)

*Store Name

How did you learn about Pitman Creek Wholesale?

*Has this store location had an account with Pitman Creek previously? YesNoUnknown

*Phone

Fax

*Number of years the business has been established.

*Yrs Current Owner

*Accounts Payable Contact (Human)

*Accounts Payable Phone

Accounts Payable Cell Phone

Accounts Payable Fax

*Accounts Payable Email

*Store Email Address

*Confirm Store Email Address

*Business Type Sole ProprietorPartnershipLLCCorporation

*Federal Tax ID

*Store Manager

*Fishing Tackle Buyer (Human)

Buyer Phone

Buyer Cell Phone

Buyer Email

Shipping Address

Foreign accounts: This MUST be a USA address/Shipping Hub.

*Shipping Address

Address 2 (Apt/Building #)

*Shipping City

*Shipping State -Please Select-N/AALASKAALABAMAARKANSASARIZONACALIFORNIACOLORADOCONNECTICUTDISTRICT OF COLUMBIADELAWAREFLORIDAGEORGIAHAWAIIIOWAIDAHOILLINOISINDIANAKANSASKENTUCKYLOUISIANAMASSACHUSETTSMARYLANDMAINEMICHIGANMINNESOTAMISSOURIMISSISSIPPIMONTANANORTH CAROLINANORTH DAKOTANEBRASKANEW HAMPSHIRENEW JERSEYNEW MEXICONEVADANEW YORKOHIOOKLAHOMAOREGONPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVIRGINIAVERMONTWASHINGTONWISCONSINWEST VIRGINIAWYOMING

*Shipping Zip

Mailing Address

*Mailing Address

Address 2 (Apt/Building #)

*Mailing City

*Mailing State -Please Select-N/AALASKAALABAMAARKANSASARIZONACALIFORNIACOLORADOCONNECTICUTDISTRICT OF COLUMBIADELAWAREFLORIDAGEORGIAHAWAIIIOWAIDAHOILLINOISINDIANAKANSASKENTUCKYLOUISIANAMASSACHUSETTSMARYLANDMAINEMICHIGANMINNESOTAMISSOURIMISSISSIPPIMONTANANORTH CAROLINANORTH DAKOTANEBRASKANEW HAMPSHIRENEW JERSEYNEW MEXICONEVADANEW YORKOHIOOKLAHOMAOREGONPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVIRGINIAVERMONTWASHINGTONWISCONSINWEST VIRGINIAWYOMING

*Mailing Zip

Owner / Partners / Officers

*Full Name

Title

*Home Phone

*Driver's License #

*Home Address

Apt/Building #

*City, State, Zip Code

Full Name

Title

Home Phone

Driver's License #

Home Address

Apt/Building #

City, State, Zip Code

Bank Reference

*Name of Bank

Contact Name

Bank Street Address

Apt/Building #

*City, State, Zip Code

*Business Checking Account Number

Business Loan Account Number

*Phone

Fax

Trade Reference 1

*First Trade Reference Choose a Reference from this ListAcuSportAll SportsAmerican Rod & GunAWR SportsBig Rock SportsCSI SportsEagle ClawEllett Brothers, LLCFarris Brothers Inc.FolsomG. LoomisHenry'sHicksHoyt USALucky Craft Maurice Sporting GoodsMT SportsNabatak Inc.P-LinePape'sPradcoPrecision Shooting Equip. (PSE)ShimanoSimmons Sporting GoodsSproSports SouthStrike KingWright & McGillYamamoto BaitsZebcoOther

(If "Other") Name of Trade Reference

Account #

Street Address, Apt/Building #

City, State, Zip

Phone

Fax

Trade Reference 2

*Second Trade Reference Choose a Reference from this ListAcuSportAll SportsAmerican Rod & GunAWR SportsBig Rock SportsCSI SportsEagle ClawEllett Brothers, LLCFarris Brothers Inc.FolsomG. LoomisHenry'sHicksHoyt USALucky Craft Maurice Sporting GoodsMT SportsNabatak Inc.P-LinePape'sPradcoPrecision Shooting Equip. (PSE)ShimanoSimmons Sporting GoodsSproSports SouthStrike KingWright & McGillYamamoto BaitsZebcoOther

(If "Other") Name of Trade Reference

Account #

Street Address, Apt/Building #

City, State, Zip

Phone

Fax

Trade Reference 3

*Third Trade Reference Choose a Reference from this ListAcuSportAll SportsAmerican Rod & GunAWR SportsBig Rock SportsCSI SportsEagle ClawEllett Brothers, LLCFarris Brothers Inc.FolsomG. LoomisHenry'sHicksHoyt USALucky Craft Maurice Sporting GoodsMT SportsNabatak Inc.P-LinePape'sPradcoPrecision Shooting Equip. (PSE)ShimanoSimmons Sporting GoodsSproSports SouthStrike KingWright & McGillYamamoto BaitsZebcoOther

(If "Other") Name of Trade Reference

Account #

Street Address, Apt/Building #

City, State, Zip

Phone

Fax

Payment Information

The terms you choose will determine the speed at which the application is processed.

*Terms Requested eCheck (requires a good bank reference)Net 15 (requires good bank and industry references)Credit Card (fastest access/terms apply)

*Anticipated Monthly $ Volume with Pitman Creek 7501,5002,000,2,5005,000,10,00015,00025,000

Total Annual Sales (All Products)

Total Annual Fishing Sales

*Has this business or any of the principals ever been bankrupt? NoYes

If yes, please explain

Getting To Know You

Help us better understand your business by answering a few additional questions.

Other

What are your top freshwater brands?

What are your top saltwater brands?

Any additional ways to contact you. (Cell numbers, emails etc.)

This application is intended for the sole purpose of Pitman Creek Wholesale extending open account status to its customers. This information is the property of Pitman Creek Wholesale and is not to be distributed to any parties outside of our Credit and/or Sales Departments.

Upload Store Photos

If you are able to upload the following files your application will progress more swiftly. If not, the photos may be emailed to info@pitmancreek.com and the forms may be faxed or emailed. f. 859-439-2060

Upload photo of the front of your store
Photos help us verify the authenticity of a retail location.

(Max file Size: 10 Megabytes)
Upload

Upload photo of the interior of your store
Photos help us verify the authenticity of a retail location.

(Max file Size: 10 Megabytes)
Upload

Upload photo 2 of the interior of your store
Photos help us verify the authenticity of a retail location.

(Max file Size: 10 Megabytes)
Upload

Required Forms

Signatures MUST be hand-signed by the person who owns the bank account for the bank reference provided. Signatures completed digitally will not be accepted.

Upload (email or fax) completed Consent form. (Required form, must be physically signed to be valid)

(Max file Size: 10 Megabytes)
Upload

Upload (email or fax) completed ECH form. (Required form, must be physically signed and have a voided check attached to be valid)

(Max file Size: 10 Megabytes)
Upload

Upload (email or fax) completed KY State Certificate. (Must be physically signed to be valid)

(Max file Size: 10 Megabytes)
Upload

Upload (email or fax) completed Credit Card Approval form (Must be physically signed to be valid)

(Max file Size: 10 Megabytes)
Upload