GOLD RIVER DISTRIBUTORS



1120 Tara Court Ste. 4, CA 95765

Phone (916) 408-2226 FAX (916) 409-9203

Toll Free (800) 493-2306

e-mail: info@

CUSTOMER INFORMATION FORM

Business Name __________________________________________________________

How long in Business _____________________________________________________

Seller’s Permit Number ____________________________________________________

PLEASE SUBMIT A RESALE CERTIFICATE WITH THIS FORM.

Address ________________________________________________________________

City________________________________State______________Zip_______________

Telephone_____________________________ E-Mail____________________________

Fax ___________________________________

Owner(s) or Partner(s) Names _______________________________________________

Home Address ___________________________________________________________

City________________________________State______________Zip_______________

Home Telephone________________________ E-Mail____________________________

Fax ___________________________________

This is merely a request to purchase products from Gold River Distributors and does not constitute an application for check writing. A Check Writing Application and Personal Guaranty must be submitted for check writing privileges to be considered or approved.

Authorized Signature_________________________________________Date___________________

Print Name________________________________________ Title__________________

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