BusinessIQ

General Information

^*Do you have an existing/prior account with Safilo?

^*If yes, provide the account number below. If you’ve never had an account with Safilo, type “none”.

Please note your Safilo sales representative(s)

^*Please select your Billing preference

Bill buying group- Skip to signature or Direct Billing with Safilo- continue with application

^*Please note the name of your Buying Group. If you do not belong to a Buying Group, type “none”.

^*Please select your Business Type

If other, please add

Business Information (please attach a list of any additional locations below)

^*Business Name

Doing Business As (DBA Name)

^*Tax ID

^*Shipping Address

^*City

^*State/ Province

^*Zip/Postal

Country

^*Billing Address

^*City

^*State/ Province

^*Zip/Postal

Country

^*Accounts Payable Contact Name

^*Telephone

^*Email Address

^*Telephone - Work

^*Telephone - Cell

^*Email Address

Legal Structure

^*Purchasing Contact Name

^*Purchasing Contact Telephone

^*Purchasing Contact Email Address

^*Please choose your Association

^*If “Other” please name the Association in the field below. If “None”, please type “none”.

^*Franchise?

^*If “yes” please fill in the name. If “no” please type “no".

In Which US state are you preforming business?

Safilo will use this to set Sales Tax

I hereby undertake to promptly inform Safilo in case of new State/s in which I plan to do business

Dropship and LAB information is required. In order to properly set Sales and Use Tax,

With regard to the Sales and Use Taxes applicable in the US, I declare that:

Attach the related exemption certificate

I’m aware that in case I will not provide the exemption certificate,

Safilo will be entitled to apply sales taxes accordingly to the ship to state

Trade Reference Information is required. The applicant hereby authorizes Safilo to obtain references from the businesses provided.

Reference Name

Reference Account Number

Phone Number

Reference Email

Contact Name

Phone Number

Contact Email

Reference Name

Reference Account Number

Phone Number

Reference Email

Contact Name

Phone Number

Contact Email

Reference Name

Reference Account Number

Phone Number

Reference Email

Contact Name

Phone Number

Contact Email

Bank Reference Information is required. The applicant hereby authorizes Safilo to obtain a reference from the Bank provided.

Bank Name

Bank Account Number

Bank Phone Number

Bank Contact Name

Guarantor (owner, partner, or other responsible party who personally guarantees payment to Safilo)

^*Principal First Name

Principal Middle Name

^*Principal Last Name

^*Principal Home Address

^*City

^*State/ Province

^*Zip/Postal

^*Telephone - Home

^*Telephone - Work

^*Principal Email Address

^*Principal Social Security Number (SSN)

^*Personal Guarantee Authorization (Y/N)
Yes No

Guarantor Signature

^*Signature Of Guarantor

^*Title

^*Date

Submission

*() Upon completion, please ensure to click Submit.**

Attachments

If your business is Sales Tax Exempt, your Certificate must be attached below. If the credit limit requested is $50,000.00 or more, your last year-end and most recent Financial Statements must be attached. (Financial Statements are: Balance Sheet, Income Statement, Cash Flow Statement, Statement of Changes in Equity.) Feel free to attach any other document(s) that are relevant to the Application decision process.

Attachment Description

Attachment Location

Note: Accepted file formats include PDF, CSV, TXT and various image files (JPEG, JPG, GIF, BMP, TIFF, TIF, PNG, ICO). File attachments must not exceed 10 MB in combined size.

Terms and Conditions

^*Signature of Applicant

^*Title

^*Date

PRINT AGREEMENT

I agree to the terms and conditions specified above.

User Verification

Please complete the following by entering the value EXACTLY how it appears(case sensitive)

Why do I have to do this?