Wholesale

Wholesale application

Complete the form below. Our team will review your application and connect you with a sales representative.

New Account Form

STORE NAME *

CONTACT NAME *

EMAIL ADDRESS *

PHONE NUMBER *

BILLING ADDRESS*

Street Address *

Address line 2

City *

State *

Postal / Zip Code *

SHIPPING ADDRESS*

Street Address *

Address line 2

City *

State *

Postal / Zip Code *

DO YOU HAVE A WEBSITE? IF SO, LIST IT HERE:

CREDIT CARD AUTHORIZATION

By signing below, you authorize charges to your Visa, MasterCard, American Express or Discover card indicated in this authorization form according to the terms outlined herein. You will be charged for the total amount due for the shipment of order(s) you placed with Dear John Denim, Inc. ("Dear John"). The receipt and invoice will be provided along with shipment to you and the charge will appear on your credit card statement. If the payment date(s) fall on a weekend or holiday, you understand that the payments may be executed on the next business day. You understand that this authorization will remain in effect until you cancel it in writing, and you agree to notify Dear John in writing of any changes in your account information or termination of this authorization at least 15 days prior to the next billing date. This payment authorization is for the type of bill indicated above. You certify that you are an authorized user of this credit card and that you will not dispute the scheduled payments with my credit card company provided the transactions correspond to the terms indicated in this authorization form. Please select ONE option below:

PLEASE SELECT ONE OPTION BELOW:*

I hereby authorize Dear John to charge the balance due on my account for all open order(s). You agree that no prior-notification will be provided if the total payment is under $5000.00 (USD) If your bill is more than that amountI hereby authorize Dear John to charge the balance due on my account 3 days after email notification to the email address designated by me.

CUSTOMER NAME *

Request to factor application

CUSTOMER BILLING ADDRESS*

Street Address *

Address line 2

City *

State *

Postal / Zip Code *

CREDIT CARD NUMBER *

EXPIRATION DATE *

SECURITY CODE *

THE UNDERSIGNED GUARANTEES PERFORMANCE OF THE FINANCIAL PROVISIONS OF THIS AGREEMENT.

VERIFY E-SIGNATURE*

I HEREBY CONSENT TO ELECTRONIC SIGNATURE BELOW.

DATE *

CARD HOLDER NAME *

Being the authorized cardholder or the Corporate Officer, by signing above, I understand and agree to the terms set forth in this agreement, agree to pay, and specifically authorize to charge the above credit card for the shipment provided. I further agree that in the event my credit card becomes invalid, I will provide a new valid credit card upon request, to be charged for the payment of any outstanding balances owed.*

NOTES