| Dealer
Application Please print then fax or mail Toll-Free: 800.EYES.4U2 Phone: 707.829.2020 Fax: 707.829.2122 |
Allyn Scura Eyewear |
| Company Name: |
| Owner's Name: | Buyer's Name: |
| Street: | Unit#: |
| City: | State: Zip: | Country: |
| Phone:( ) | Fax:( ) |
| Email: |
| Additional Locations: |
| Store Info: Please submit a photo of the exterior as well as the interior of your shop and mail to the above address or e-mail a digital image. |
| -Optical Shops please list your best selling lines: |
| -Please give a brief explanation of your business and who your customers are: |
| Payment Terms: Cashier's Check, Money Order, Credit Card or Company Check (product ships after payment is cleared). We accept MC, Visa, American Express & Discover. I have read and understand the policies section and agree to all of the terms and conditions contained therein. |
| Type of Credit Card: |
| Name on Credit Card: |
| Credit Card #: | Expiration Date: |
| Signature: |
| All initial orders are COD or CIA by the payment terms above. Please complete the section below to apply for extended dating. |
| # of Years in Business: | # of Employees: | Annual Gross Sales:$ |
| Name of Bank: | Years Banking There: |
| Name of Account: | Account #: |
| Bank Contact: |
| Terms: I agree and understand that if my account is over 30 days past due, Allyn Scura Eyewear has my permission to charge my credit card as payment. |
| Signature: |