Retailers Application

Name of owner:
Name of business:  Years in business:
Address:  City:  State:  Zip:
Phone:  Fax:  Tax ID:
Web URL:  Email:

Business Owner(s):  Sole Proprietor   Partnership   Corporation   LLC  
                                     Other
Available sq. ft. for product and display:
List Major Products you currently sell or intend to sell:

Credit References: Please provide 3 references from companies you currently buy product from.
Name:  Address:
Contact Person:  Phone:

Name:  Address:
Contact Person:  Phone:

Name:  Address:
Contact Person:  Phone: