New Account Setup Form

Manual Override

1. Company information

Company

Company's legal name (if different)

First Name

Last Name

Title

Phone

ext.

HOW_FIND_US

2. Billing/Accounting Information

Accounting Contact First Name

Accounting Contact Last Name

Title

Phone

ext.

Address line 1

Address line 2

Country

State

City

Postal Code

3. Shipping information

*Check here if same as billing information

Attention

Department

Phone

ext.

Address line 1

Address line 2

Country

State

City

Postal Code

Receiving contact email

Receiving contact phone

ext.

Specify

Receiving hours

Credit card payment authorization form

Please sign and complete this form to authorize Entreprises JESEMI to make a debit to your credit card listed below..

By signing this form you gives us permission to debit your credit card account for all invoices rendered.

IMPORTANT: If at any given date this information changes, please contact our office immediately to update your account information. It is our company policy that a valid credit card must be on file at all times. This also applies to all types of accounts, including NET 30.

Manual Override

(full name)

authorize Entreprises JESEMI to charge my credit card.

*Check here if same as billing information

Business name

Address

City

Postal Code

Country

State

Phone

ext.

Account number

VISA

MASTERCARD

Account Type

Cardholder name

Expiration date

CVV2 (digits in the back of card)

I authorize Jesemi Distribution to charge the credit indicated in this authorization form according to the terms outlined above, I certify that I am an authorized user of this credit card card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

Signature

Date: 01/16/2025

By checking this box, you have read and agree to our sales terms and conditions