Old Chicago Coffee Co. - Dropship Request

Fields marked with a red * are required in order to submit your request.

There is a one time $35.00 account set-up fee and a monthly subscription to our services of $10.00 per month..
Your card is only charged if your account is approved.
There are no per-order dropship fees, only actual dropship order totals.

Name on Card: * Credit Card Number: * Expiration Date: * CCV Code (3 digits on back of card): *
Contact Person:*
Contact Email:*
Company Name:* must not contain trademarks unless you own
Street Address:*
Address 2:	(optional)
City / Town / Village:*	State:* Zip Code:*
DUNS Number:
Federal Tax ID Number (EIN)* (not social security #) Federal Tax Number Required
State of Incorporation:* Valid/Active Corporation/LLC/LLP Required To Apply NO CORPORATION? GET STARTED EASILY AT: incorporate.com
Link to your State's Company Lookup: Leave blank if unknown, we have a list of state databases.
Your Company Website Address:
Preferred Password for Dropship Cart:* Make sure you remember this.
The information below is required by the State of Illinois, Department of Revenue, and must be filled out for tax free sales. We are required to have this information in our files regardless of your location. Illinois Form CRT-61 Step 2, Step 4 and Step 5 are Required
* CRT-61 - Step 2, Line 5: Answer 1 of the 3 items below.
1: I am registered as a Retailer with the Illinois Department of Revenue and my 8 digit Account ID Number is:
2: I am registered as a Reseller with the Illinois Department of Revenue and my 8 digit Accound ID Number is:
3: I am authorized to do business out-of-state and will resell and deliver property only to purchasers located outside the State of Illinois. (place an X in the box to the right if this applies)
* CRT-61 - Step 4, Line 7: Check only 1 of the 2 items below.
I am the identified purchaser and I certify that all of the purchases that I make from Old Chicago Coffee Co. are for resale.
I am the identified purchaser and I certify that the following percentage, %, of all the purchases that I make from Old Chicago Coffee Co. are for resale.
* CRT-61 - Step 5 Digital Signature of Purchaser
I certify that I am purchasing Coffee Products for the purpose of resale and give permission to charge my card for the account set-up fee of $35 USD and monthly subscrption of $10 USD starting one month after account activiation (cancel anytime). I have read and agree to the Terms & Conditions. including the section about user submitted content.
Digital Signature: *
Date Signed: *
Optional Comments: