Vetra Systems US Reseller Online Application Form

Vetra Systems Reseller Application (within US)

Thank you for your interest in becoming a Vetra Systems Reseller. Please read the important requirements and complete the application below.

Important Requirements:
1) If your business is a general / limited partnership or sole proprietorship, please complete the Personal and Credit / Bank Information in Section 2 of this form.

SECTION 1:

Business Trade Name (DBA):
Business Legal Name:
Billing Information:
Bill to Address 1:
Bill to Address 2:
Bill to City:
Bill to State:
Bill to Zipcode:
Shipping Information:
Ship to Address 1:
Ship to Address 2:
Ship to City:
Ship to State:
Ship to Zipcode:
Contact Information:
Name of Primary Contact:
Contact Phone Number:
Contact Fax Number:
Contact Email Address:
Company Website URL:

Type of Business:
Payment Terms for Initial Purchases:	Credit Card COD Prepay
Do you wish to apply for a NET 30 Account:	No Yes
If yes, an account representative will contact you with our application requirements.

SECTION 2:
Complete For Partnerships and Sole Proprietorships Only

Owner or Partner 1 Name:
Owner or Partner Address 1:
Owner or Partner Address 2:
Owner or Partner 1 City:
Owner or Partner 1 State:
Owner or Partner 1 Zipcode:
Owner or Partner 1 Home Ph:
Have you ever filed for bankruptcy?:	No Yes

Partner 2 Name:
Partner Address 1:
Partner Address 2:
Partner 2 City:
Partner 2 State:
Partner 2 Zipcode:
Partner 2 Home Ph:
Have you ever filed for bankruptcy?:	No Yes

Business Bank Information:
Name of Bank:
Bank Address 1:
Bank Address 2:
Bank City:
Bank State:
Bank Zipcode:
Bank Phone Number:
Account Officer Name:
Bank Account Number:

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VETRA Systems Corporation
275 Marcus Blvd. Suite J Hauppauge, NY 11788-2022 USA
Toll Free 1-800-537-9296
Tel: 631-434-3185 Fax: 631-434-3516 e-mail: sales@vetra.com