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Admin
Customer
Application Form
Welcome to Wix. Please fill out the form below!
Company Information
Legal Name:
Brand Name:
VAT Number:
Registration Number:
Address:
City:
Zip:
State (Region):
Country:
Legal Representative
Full Name:
Email:
Additional Information
Business Line:
Main Activity with Wix:
Principle Trade Currency:
Annual Income (USD):
Company Size
Billing Information
Is Billing Information same as Company Information?
*
Required
Yes
No
Bill to Name:
Bill to Email:
Address:
City:
Zip:
State (Region):
Currency:
Country:
Is a PO (Purchase Order) Number required to book the invoice?
*
Required
Yes
No
Procurement Contact Name
Procurement Contact Title
Procurement Contact Email
Account Payable Contact Person
Full Name:
Email:
Title:
Office Phone:
Office Mobile:
Send
Thanks for submitting!
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