APPLICATION FOR
CREDIT CARD ACCEPTANCE

(FORM MUST BE COMPLETE FOR PROCESSING)
   
Store Name:
Address:
City:

State/Province:
Zip/Postal Code:
Owner's Name:
Business Phone:
Owner's Home Address:
Owner's Home Phone:
Email:
Fax:
State Resale #:
# of years in business:
This location is a: Residence Business
   
Bank Name:
Account #:
Bank Address:
Telephone #:
Are you rated by Dun & Bradstreet? Yes No
D & B #:
Rating:
How many years have you owned this business?
 

Credit Card Information
Please Select One: Visa MasterCard Discover
Card Number :
Expiration Date:
Cardholder Name:
   

I authorized E & R Sales to charge my order to the above account.

Signature
 
Authorized Signature
Title:
Date:
 
 

E & R Sales
4800 Market Square Lane
Midlothian, VA 23112
1-800-234-7474
Fax: 804-744-5125