Tharanco Lifestyles Client Portal

Greg Norman Tourney Dunning

Dealer/Company Name:

DBA/TA (if applicable):

Street Address:

City:

State:

ZIP Code:

Business Phone:

Federal ID#:

Fax Number:

S/S#:

Email Address:

Primary Contact Name:

Addresses of Ship to Locations:

Same as Bill to? Yes No

Street:

City:

State:

ZIP Code:

Salesperson:

STORE LOCATION:

(LIST ADDESS OF EACH RETAIL LOCATION WHERE MERCHANDISE WILL BE SOLD)

Same as bill to? Yes No

Store Phone #:

Store DBA:

Store Address:

Street:

City:

State:

ZIP Code:

Type of Organization:

Type of Business:

Date Started:

Name of Bank:

Phone #:

Checking Account #:

Principals:

Name:

Street:

City:

State:

Zip:

Telephone:

Trade:

Name:

Street:

City:

State:

Zip:

Telephone:

Account No#:

MARKETING / PR CONTACT:

Same as Bill To? Yes No

Commercial Customer Name:

Street Address:

City:

State:

ZIP Code:

Phone #:

Fax #:

Primary Marketing Contact Name:

Email:

Signature of Officer or Partner:

THE UNDERSIGNED CERTIFIES THAT THIS AUTHORIZED RETAIL DEALER AGREEMENT IS MADE ON BEHALF OF THE APPLICANT SHOWN HEREIN FOR THE PURPOSE OF SECURING OPEN ACCOUNT TERMS OF CREDIT FROM THE COMPANY, AND THAT THE CONTENTS HEREOF AND THE FINANCIAL DATA SUBMITTED HEREWITH ACCURATELY REPRESENT THE FINANCIAL CONDITION, WITHOUT MATERIAL CHANGE, OF THE APPLICANT TO THIS DATE. I UNDERSTAND THAT YOU WILL RELY ON THE INFORMATION IN THE CREDIT APPLICATION IN EXTENDING CREDIT TO ME, AND MY SIGNATURE ON THE APPLICATION IS MY PLEDGE THAT YOU ARE AUTHORIZED TO INVESTIGATE MY/OUR FINANCIAL CREDIT WORTHINESS, CREDIT HISTORY, AND FINANCIAL CREDITORS NOW AND IN THE FUTURE. WE ALSO AUTHORIZE BANKS AND OTHER INSTITUTIONS TO GIVE INFORMATION TO THE NAMED CREDITOR IN CONNECTION WITH THIS OR FUTURE TRANSACTIONS ABOUT MY/OUR SAVINGS, CHECKING, AND/OR LOAN HISTORY.

Regional Sales Approval:

Date:

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