REQUEST TRADE ACCOUNT

*Company Name: Enter Company Name

Required

*City: Enter City

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*Contact First Name: Enter Contact First Name

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*ZIP Code: Enter ZIP Code

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*Do you currently have an account with our affiliate company, Chelsea House? :

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Yes

No

Not Sure

*State: Enter State

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*Phone Number: Enter Phone Number

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*Email for Contact: Enter Email for Contact

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*Email for Orders & Invoices: Enter Email for Orders & Invoices

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*Federal Tax ID Number: Enter Federal Tax ID Number

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*Business Type:

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Retail Store (1)

Retail Store - Multiple Locations (2)

Interior Designer

Contract/Hospitality Designer

Lighting Showroom

Office Equipment Dealer

International Customer

Website: Enter Website

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*Years in Business: Enter Years in Business

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Ship to Name: Enter Ship to Name

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Shipping Address: Enter Shipping Address

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City: Enter City

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State: Enter State

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ZIP Code: Enter ZIP Code

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City: Enter City

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State: Enter State

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ZIP Code: Enter ZIP Code

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Email for FedEx Tracking Information: Enter FedEx Tracking Information

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FedEx/UPS 3rd Party Account Number: Enter FedEx/UPS 3rd Party Account Number

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Freight Carrier of Choice: Enter Freight Carrier of Choice

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Receiver/Warehouse Name: Enter Receiver/Warehouse Name

Required

Receiver/Warehouse Address: Enter Receiver/Warehouse Address

Required

Special Freight Instructions: Enter Special Freight Instructions

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Freight Type:

Required

Prepaid

Collect

Third Party

Reference Name #1: Enter Reference Name #1

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Email: Enter Email

Required

Phone Number: Enter Phone Number

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Reference Name #2: Enter Reference Name #2

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Email: Enter Email

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Phone Number: Enter Phone Number

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Reference Name #3: Enter Reference Name #3

Required

Email: Enter Email

Required

Phone Number: Enter Phone Number

Required

*Company Address: Enter Company Address

Required

Notes: Enter Your Notes

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*Contact Last Name: Enter Contact Last Name

Required

Sales Tax ID (only if located in NC): Enter Sales Tax ID

Required