Customer Information
Customer Number Phone Number
Customer Name
Physical Address Date of Contact
City State Zip Code
Account Contact Name #1
Account Contact Name #2
Account Contact Name #3
Marketing Rep
Current Supplier Information
Name of Supplier Current Terms COD 7-Day 14-Day Total Weekly Purchases
Current Pricing
Regular Cigs Generic Cigs 4th Tier Cigs 36ct Candy
24ct KS Candy Scrap Tobacco Smokeless Tobacco
Gatorade Goody's
General Comments
Expected Purchases from this Account??
Total Cigarettes Cartons Cigarettes Dollar Amount
Other Merchandise (Dollars) Total Weekly Purchase (dollars)
Did you mention the minimum order if so what was the amount?
Does potential Customer Have an email address, if so please list
Was Credit Application Filled out? YES NO