New Account Application

ACCOUNT INFORMATION

Date:
Business Name: *
Type of Account:*
Retail Store:	Physician/Practitioner	Online Retailer
Website Address (URL)
Shipping Address (Street) *
City*
State*
Zip*
Telephone No.: *
Fax No.:
E-mail
Contact Person: *
Federal ID or SS# Seller's Permit No.:
Where and how did you hear about JFI:

PERSON RESPONSIBLE FOR PAYMENT
(If Business is Sole Proprietorship)

ACCOUNTS PAYABLE DEPT. INFORMATION
(If Business is a Partnership or Corporation)

For security of your information, you may also download the PDF version this of page and fax it to our Los Angeles office.