Dealer Application

1540 Lowell Street · Elyria, Ohio 44035 · 1-800-325-3118 · Fax: 800-214-1733

Please fill out all relevant information, then click the 'Submit Application'
button at the bottom of the form to submit your application to us. Please note
that fields *highlighted in red* are required.

Contact Information
Date Business Opened
Referred By
Firm name
Contact Name
Email
Telephone	Fax
Cell Phone
Billing Information
Billing Address
Address Line 2
City	State ZipCode
Email for Invoices
Ship-To Information (If different from billing info above)
Ship-To Address
Address Line 2
City	State ZipCode
Company Information
Name of Owner	(if proprietorship or partnership)
Parent Company	(If subsidiary or division)
Address
Address Line 2
City	State ZipCode
Your Bank Information
Bank Name
Credit Limit Requested
Address
Address Line 2
City	State ZipCode
Phone
D & B Number	(if known)
Principal Supplier #1
Name
Your Account No.
Address
Address Line 2
City	State ZipCode
Phone	Fax
Contact
Principal Supplier #2
Name
Your Account No.
Address
Address Line 2
City	State ZipCode
Phone	Fax
Contact
Principal Supplier #3
Name
Your Account No.
Address
Address Line 2
City	State ZipCode
Phone	Fax
Contact
Principal Supplier #4
Name
Your Account No.
Address
Address Line 2
City	State ZipCode
Phone	Fax
Contact

CREDIT INFORMATION RELEASE AUTHORIZATION

The undersigned authorizes and grants to EM PRINT GROUP, permission to obtain complete credit information concerning the undersigned. Further, the undersigned warrants and represents that all information contained in this application and any other statements or documents submitted by the undersigned are true, accurate, correct and complete. A late charge will be assessed on accounts paid beyond our terms.

*Your Name*

*Your Title*