Credit Card Authorization

Company Identification
Legal Company Name*
Trade/DBA Name
Organization Type*
State of Business*
State / Province / Region
Business Established*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Federal Tax ID*
DUNS Number
Tax Exempt/Resale/Other Certificates
Tax Exempt or Resale/Other?*
- No
- Yes
Sales & Use Tax Exemption/Resale - Multijurisdiction?*
- No
- Yes
Streamlined Sales & Use Tax Agreement?*
- No
- Yes
Business Profile
Style of Business*
Number of Employees*
Annual Sales*
Applicant Contact Info
Title*
Registration Information*
First Name Last Name
Work Phone*
Fax
Email*
Enter Email Re-Type E-Mail

Customer P.O. No.:
Web site:
Email Address All invoices and statements are provided electronically to the Email addresses indicated in this box. If hard copies of these documents are required, a member of Basilio Inc's credit team may be contacted.
Primary Contact Email Address:*
Email Address for Invoices:
Email Address for Statements:
CREDIT CARD INFORMATION
BASILIO INC DOES NOT ACCEPT PAYPAL OR DEBIT CARDS. BY SUBMITTING AND SIGNING THIS SECTION YOU AGREE TO THE TERMS ATTACHED
Customer represents that it is the cardholder, is authorized to use the credit card(s) and authorizes Basilio Inc to process all payments on this credit card(s) regardless of the ship-to address. It is not necessary that the ship-to address and Customer billing address are identical. Any and all charges for product ordered on Customer’s account, regardless of shipping destination, are the responsibility of Customer and will be charged to the credit card(s) authorized herein. Customer understands that by utilizing a debit card for payment, the issuing financial institution may subject Customer’s account to an authorization hold. An authorization hold is a common banking industry practice by which Customer's financial institution places a hold on any available balance equal to Customer's purchase amount while Petra processes payment. The exact dollar amount and the time frame for a release of any authorization hold are set by Customer’s financial institution. Basilio Inc shall not be responsible for any fees or charges incurred as a result of Customer’s use of a debit card, including, but not limited to any fees or charges incurred by Customer as a result of an authorization hold. Customer is responsible for understanding its particular financial institution’s policies regarding authorization holds and the specific effects on Customer’s financials. Customer also agrees to abide by Basilio Inc’s Standard Sales Terms and Conditions (found at www.basilioinc.com / terms) and any other applicable terms and conditions set by Basilio Inc and available upon request by Customer. Customer hereby authorizes Basilio Inc to process payment for all orders made by fax, phone or email to the above-referenced credit card. These orders will be made by the above-listed authorized users. Any changes such as adding or deleting users will be made in writing to Basilio Inc. Customer assumes responsibility for payment
Card Type*
Expires*
Date Format: MM slash DD slash YYYY
Please print name EXACTLY as it appears on card:*
Authorized users:*
Billing Address of Card Holder:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Signature
Sales / Order Information E-Comm Customers Are Required to Provide Fulfillment Services Agreemen
Agree to FSA Form for E-Comm Customers Here
Basilio Inc Sales Representative
Basilio Inc Representative
Our Business is a
Do you sell products online?
General description of my business*
Number of Stores
We will be purchasing products from Basilio Inc for*
- Select All
- Resale
- Business Use

Attach Credit Documents
Drop files here or
Articles of Incorporation, Misc. Documents, SS-4, Reseller Certificates, Seller License, & Other Pertinent Documents

Credit Card Authorization Form

Company Identification

Tax Exempt/Resale/Other Certificates

Business Profile

Applicant Contact Info

Email Address All invoices and statements are provided electronically to the Email addresses indicated in this box. If hard copies of these documents are required, a member of Basilio Inc's credit team may be contacted.

COMPANY INFO

CUSTOMER SERVICE

RESOURCES