Account Applications for E-Opals

Account Application for E-Opals.com

To become an E-Opals.com retail jeweler/memo merchant and capitalize on the efficiencies of e-business for your opal jewelry and gem needs, simply fill out this form and submit it. All the information is required to be approved. You will be notified by email within 48 hours of your E-Opals.com ID access number and password. If you have any questions or an urgent opal request, please CALL us at 1-800-376-6725, fax us at 405-495-6611 or email us.


	.	Company Information

Important! 1. E-Opals.com guarantees that the information below will be kept strictly confidential. 2. All the information on this form is required to be approved. 3. All fields with an "*" is required information.
Special characters such as # are not recognized by our system. Please do not use # when inputting apartment or office numbers.



*Contact Name:		.

*Company Name:

*Billing Address Line 1:

Billing Address Line 2:*

*City:		.	*State:

*Zip Code:

*Phone #:	- -	.	Ext.:

Fax Number:	- -

*Federal Tax Id Number:

*Email Address:

If you were referred to E-Opals.com by someone, please tell us the Referrer's Name

*Person Responsible for Accounts Payable:


	.	Bank Information

Important! 1. E-Opals.com guarantees that the information below will be kept strictly confidential. 2. All fields with an "*" is required information.
Special characters such as # are not recognized by our system. Please do not use # when inputting apartment or office numbers.

Bank 1:

*Bank Name
*Address
*City, State, Zip
*Contact
*Phone
*Account Number

Bank 2:

Bank Name
Address
City, State, Zip
Contact
Phone
Account Number


	.	Reference Information

Important! 1. E-Opals.com guarantees that the information below will be kept strictly confidential. 2. All fields with an "*" is required information.
Special characters such as # are not recognized by our system. Please do not use # when inputting apartment or office numbers.

Reference 1:

*Company Name
*Address
*City, State, Zip
*Contact
*Phone
*Account Number

Reference 2:

*Company Name
*Address
*City, State, Zip
*Contact
*Phone
*Account Number

Reference 3:

*Company Name
*Address
*City, State, Zip
*Contact
*Phone
*Account Number

Reference 4:

*Company Name
*Address
*City, State, Zip
*Contact
*Phone
*Account Number


	.	Other Information

Important! 1.E-Opals.com guarantees that the information below will be kept strictly confidential. 2. All fields with an "*" is required information.
Special characters such as # are not recognized by our system. Please do not use # when inputting apartment or office numbers.

* If you already have a website, please enter your website address here:

* If you do not have a website but would like one Yes No

* Yes this is my signature.

*Type your name here:

ELECTRONIC SIGNATURE: By typing in my name above, I acknowledge and authorize Opals International Jewelers, Inc. (E-Opals.com) to validate my banking and credit references. This agreement is between Opals International Jewelers, Inc. and the undersigned firm and/or representative. Credit extention is requested on the basis of the above information.

Standard terms are: Memos:10 days

Invoices: Good Credit Standing, 30 days

Please make your comments regarding your E-Opals.com retail jeweler/memo registration below:

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