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Dealer Registration Form

Please check all that apply to your business

Drop Ship    Retail Store     Online     Distributor Mail Order Designer

Contact Name:   *  Prefer Login Name*

Company Name:   *

Country:

Address: *

City: * State    Zip/Postal*

Province

Phone: *Fax:

Alt. Phone: Contact 2

Web site:

Email*Confirm Email: *

Resale Number / Fed. ID:

Payment Information

Company Check        Credit card       Wire transfer         Net 30 (Upon Approval)    

Billing Address: (Check here if same as shipping address) *

How did you hear about us?

Trade Show / Show Name: Internet  Source:

Other Source:

Other Information/Comments:

                

Please include a web site or fax us a copy of your resale certificate or business license

I agree*

 

 

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