Wholesale Account Application
How did you hear about VISISCREEN?
On the House Media
Other (please specify below)
Other Referral Source
If "other" option was selected above, please specify the referral source.
Enter the name of your company
Enter the full name of your designated contact person
Enter the email address of your designated contact person
Enter your contact person's phone number
The street, city, state and zip code of your primary business location
Country your business is located in
Country Shipped To
Country orders will be shipped to
Use Company Address for Shipping
Same as company address
Type of Business
Type of Business
Description of Business
Briefly describe the nature of your business
Resale Tax Number or EIN Number
Please provide three references of businesses from which you currently purchase wholesale. Include the business' name, complete address, as well as your contact's name, phone number, fax number and email address.
If you do not currently have three trade references, then please provide those you have and include additional information that would be helpful to establish your eligibility to qualify for a wholesale account with Aedes Technologies.
All information given to Aedes Technologies is kept confidential other than us contacting your bank and references.
Trade Reference #1
Trade Reference #2
Trade Reference #3
Electronic Funds Transfer (EFT)
Company Credit Card
Net 30 Days
Check one of the above. If you are requesting either the EFT or Net 30 Days options, you will also need to provide a credit application. You may email your own credit sheet to email@example.com, but we still require that an authorized person sign our copy and Exemption Certificate (Sales Tax Exemption form). APPLICATIONS SENT WITHOUT A COMPLETED CERTIFICATE OF EXEMPTION WILL NOT BE PROCESSED. Download our credit application and Sales Tax Exemption Form below, complete the appropriate sections and then email to firstname.lastname@example.org.