New Customer Profile Form

Please fill out the following information to open a Wholesale Account with Vintage Wholesale.
Notice: If this is your first time ordering from us your company is required to turn in a New Customer Profile form

Company Information

Today's Date (required)

Company Name (required)

DBA (If different the Company Name)

Please tell us what kind of items you are interested in

Street Address (required)

City (required)

State or Province(required)

Zip Code(required)

Country(required)

Shipping Address (If different the Billing Address)

Street Address

City

State or Province

Zip Code

Country

Email (required)

Accounts Payable Phone Number (required)

Accounts Payable Fax Number (if available)

Federal Tax ID (if available)

Sales and Use Tax (if available)

Year Business Was Established(required)

Do you own or lease your location(required)

What type of Items are you interested in (required)

Officer/Owner First Name (required)

Last Name (required)

Title (required)

Partners/Managers/Buyers Names:


Shipping InformationOptional
Please fill in the following information if you have your freight arrangements already worked out

Shipping Company:

Account Number:


Trade ReferencesOptional
Please feel in the following information if you have any Trade References

Company (one):

Company Name:


Account Number:


Telephone Number:


Contact Name:

Company (two):

Company Name:


Account Number:


Telephone Number:


Contact Name:

Company (three):

Company Name:


Account Number:


Telephone Number:


Contact Name:


Please review our Terms and Conditions before placing an order

*We need to make sure that you are a real person, please type the characters that appear in the picture below.
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Letters are not case-sensitive

Send Me Updates and Specials!

Once your account information has been accepted you will receive an email response to the email provided on the form with a new account number to view our online catalog and order form. (Please Note this may take up to 24 hours) Please feel free to contact us if you have any questions or problems receiving your confirmation email.