Bus Start Date: Type of Credit Card: ... I, the undersigned, authorize Motivation Design LLC, dba Kurgo Products, to cha
Kurgo Retail Account Application Fax this form together with a copy of your tax resale certificate to 815-642-0182, or e-mail to
[email protected] Company Name:
Main Contact Name:
Ship-to Address:
Title:
City/State/Zip:
Tel/E-mail:
Tel/Fax:
Billing/AP Contact Name:
Billing Address (if different):
Title:
Billing City/State/Zip:
Tel/E-mail:
Business Classification: Sole Proprietor
Partnership
Tax ID #
Business Type:
Corporation: State
D&B Number:
Bus Start Date:
Retail Store
Veterinary
Web/Online Store (list URLs)__________________________
Grooming/Daycare
Training
Other (Pls describe) _________________________________
Are you stocking goods or drop shipping? ! Stock ! Drop Ship
Who do you purchase Kurgo items from? ! Kurgo directly ! Other distributor ___________________________
Credit Card Authorization
(If you would prefer 30-day terms, please contact Kurgo for a credit application.)
Type of Credit Card: Visa
Mastercard
Credit Card Number
Print Name as it appears on card
American Express
Other
Expiration Date:
Sec Code
Billing Address for Card
I, the undersigned, authorize Motivation Design LLC, dba Kurgo Products, to charge the above referenced credit card each time an order is placed by me. AUTHORIZED CARDHOLDER SIGNATURE The above information is submitted for the sole purpose of opening an SIGNED account and I hereby certify the information to be true. Further, I hereby agree to abide by Kurgo's Terms and Conditions, MAP Guideline, and Unilateral E-Commerce Policy, and to notify Kurgo of any URL prior to selling TITLE Kurgo products online. I understand that failure to do so may result in not DATE only loss of business with Kurgo but potential legal action for damages.
Motivation Design, LLC, dba Kurgo 2D Fanaras Drive, Salisbury, MA 01952 Tel: 877-847-3868 / Fax: 815-642-0182 / www.kurgo.com
