Required Documents: Before your application can be processed, please email your Business License and a completed, signed IRS W-9 Form to [email protected] — subject line: Wholesale Docs – [Your Company Name].  Download the W-9 here (IRS.gov).

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Full Legal Name of Business *

Trade Name / DBA (if different)

Business Type *

• Sole Proprietor
• Partnership
• Corporation
• LLC
• Other

Federal Tax ID / EIN *

State of Incorporation

Year Established

Website

Sales Tax License Number *

Primary Contact Name *

Title / Position

Phone *

Fax

Email Address *

Billing Street Address *

Billing City *

Billing State *

Billing Zip Code *

Billing Country

Shipping Street Address (if different from billing)

Shipping City

Shipping State

Shipping Zip Code

Trade Reference 1 — Company Name

Trade Reference 1 — Contact Name & Phone

Trade Reference 2 — Company Name

Trade Reference 2 — Contact Name & Phone

Trade Reference 3 — Company Name

Trade Reference 3 — Contact Name & Phone

Industry Memberships (check all that apply)

• ANA (American Numismatic Association)
• PNG (Professional Numismatists Guild)
• NGC (Numismatic Guaranty Company)
• PCGS (Professional Coin Grading Service)
• Other

Authorized Signature (Type Full Name) *

By typing your name above you agree that the information provided is accurate and you accept the terms of this wholesale application.

Date *

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