Verified By: ________________ PAGER PART MART, INC.DBA: Cell Gate USA
Approved By:________________ CUSTOMER REFERENCE & INFORMATION

Date: / / (note:this form must be filled out completely, signed and faxed to us before we
can process your order)
All information contained herein will be kept strictly confidential and will be used solely for the purposes of Pager Part Mart, Inc. Kindly write legibly or type the information. Please fax this page to 949-679-6360 along with your Reseller’s Permit. Thank you.

* Required Fields

Company Information:
*Company Name: *Contact Person:
*DBA: *Title:
*Phone: Fax:
Cell: Email:
State Reseller Certificate #:
Type of Entity:
State Tax ID#:
Federal TaxID#:
(If Corporation/LLP/LLC)
Social Security#:
(If Partnership/Sole Proprietorship)
Address:
City: State:
Zip Code:   Country:
Website Address:

Bank References:
Kindly list banking Institutions you have an account with and number of years you have been with them.
Bank Name: Contact Person:
Address: Phone No:
Account Number:

Trade References:
Other Industry accessory references are required. Kindly list a minimum of three companies from whom you purchase.
Company: Address:
City: State:
Zip: Phone #
Fax # Contact person:
Company: Address: .
City: State:
Zip: Phone #
Fax # Contact person:
Company: Address:
City: State:
Zip: Phone #
Fax # Contact person:

Your Company Buys
Phones Purchase Per Month:
Currently doing business with :
Other:

Prepaid Business
Currently doing business with:
Other indicate here:
Notes:

I/We certify that the information provided in this application and financial statements I/we might give you in connection with it, is complete and correct as of the date set forth opposite my/our signature/s on this application and acknowledge my/our understanding that any intentional or negligent misinterpretation/s may result in civil liability and / or criminal penalties including, but not limited to,fine or imprisonment or both.In case of a returned check the I/we agree to pay a $15.00 fee in addition to paying interest on payments past due at the rate of 18% per annum (or the highest allowable under applicable state law, whichever is less,) and, In case it becomes necessary for Pager Part Mart, Inc. to retain the services of an attorney to assist in the collection of any amounts past due,to pay Pager Part Mart, Inc. attorney fees.I/We understand there will be no refunds allowed after 15 days from date of invoice.I/We authorize Pager Part mart, Inc. to verify all my/our statements with any source, to periodically check my credit history, and to contact credit-reporting agencies. I/We authorize employer/s, my/our banks, and any reference listed in the application to release or verify information to Pager Part Mart, Inc. A photocopy or other reproduction of this application held by Pager Part Mart, Inc. will be considered as valid and original. I/We agree that Pager Part Mart, Inc. may obtain my/our most current residence address from the department of Motor Vehicles (CA) or Department of Highway Safety and Motor Vehicles (FL). CA residents: I/We waive the requirements of section 1808.21 of California Vehicle Code. The laws of the State of California shall govern the interpretation and enforcement.

Company Name:_______________ Authorized Signature:_______________
Date:_______________ Print Name and Title:_______________
Please make sure to fax your Reseller’s Permit along with this page to 949-679-6360. Thank you.
Approved By:_______________ Verified By:_______________