Credit Card Application

Legal Business Name:*

DBA:*

Bill To:

If different than above.

Billing Address:*

Address Line 1

City

State

ZIP Code

Ship To:*

Shipping Address:*

Address Line 1

City

State

ZIP Code

Contact Person:*

Phone:*

Fax:

Email:*

Kerusso Sales Rep:*

Web Site Address:*

State Sales & Tax Use Permit #:*

**Please Include a Sales Tax Exemption Certificate / Resale Certificate with this Application.

State:*

# of Total Locations:*

Sales Tax Exemption/Resale Certificate:

No File Chosen

File uploads may not work on some mobile devices.

Credit Card Authorization:*

Yes No

I authorize Kerusso Activewear Inc to process my credit card for all purchases.

Authorized Signature:*

Use your mouse or finger to draw your signature above

Printed Name:*

Date:*

MM/DD/YYYY

Are you the owner of the Business ?*

Yes No

Credit Card Information:

Your Kerusso Credit Representative will contact you for your credit card number and billing information.