WESTERN PACIFIC DISTRIBUTORS
1739 SABRE STREET, HAYWARD, CA 94545
510/732-0100 510/732-0155 FAX
APPLICATION FOR COD ACCOUNTTO: Western Pacific Distributors DATE:_____________________
1739 Sabre Street, Hayward, Ca. 94545
APPLICANT’S NAME___________________________________
BUSINESS NAME:_________________________________________________
BUSINESS TYPE:_______________________________________________________
MAILING ADDRESS:____________________________________________________
CITY_________________ STATE_______________ ZIP_______________________
PHONE NUMBER:_____________________FAX NUMBER:____________________
EMAIL ADDRESS_______________________________________________________
OWNERSHIP STYLE: ( ) CORPORATION ( ) PARTNERSHIP ( ) PROPRIETORSHIP
FULL NAME ( LIST ALL OWNERS)__________________________________________
HOME ADDRESS:________________________________ PHONE #_________________
SOCIAL SECURITY NUMBER _______________________________________
BUSINESS STARTED:___________________ CURRENT OWNERS SINCE:____________
OTHER BUSINESS INTREST OF OWNERS:
FIRM NAME:__________________________ ADDRESS:____________________________
BUSINESS LICENSES HELD:
STATE:________________ CLASS:____________ LINCESE#_________________________
NAME INSURED UNDER:_________________________________________________