Please complete each step below by filling in all required fields before continuing to the next step.

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Company Name(Required)

Website(Required)

Contact Name(Required)

Buyer(Required)

Company Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Fax

Business Type(Required)

Years In Business(Required)

Business License #(Required)

Please provide a copy of your current business license.(Required)

Drop files here or

Max. file size: 32 MB, Max. files: 1.

Number Of Stores(Required)

Number Of Employees(Required)

Are you a member of any buying groups?(Required)

Please list each buying group you are a member of on a new line or type none if not applicable.

Which industry trade shows do you attend?(Required)

Please list each trade show on a new line or type none if not applicable.

Do you take advantage of early booking Discounts?(Required)

Yes

No

Dealers – Who are your three main suppliers?(Required)

Click the PLUS icon to the right to add more as needed.

Distributors – Please list three references.(Required)

Click the PLUS icon to the right to add more as needed.

How many traveling sales reps are employed?(Required)

How many phone reps are employed?(Required)

Sales Associate(Required)

Business Type(Required)

Sole Proprietorship

Partnership

Corporation

Other

Bill to Name(Required)

Billing Address(Required)

Same as Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Billing Phone(Required)

Billing Fax

Billing Email(Required)

Ship to Name(Required)

Shipping Address(Required)

Same as Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Shipping Phone(Required)

Shipping Fax

Shipping Email(Required)

Owner or Principal(Required)

Business Established(Required)

Store Contact 1(Required)

Store Contact 2

State Sales Tax #(Required)

State Sales Tax # (attach copy)(Required)

Drop files here or

Max. file size: 32 MB, Max. files: 1.

Reference 1

Name(Required)

Contact(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Fax

Email(Required)

Reference 2

Name(Required)

Contact(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Fax

Email(Required)

Reference 3

Name(Required)

Contact(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Fax

Email(Required)

Signature(Required)

Retail / Distributor Customer Application

Reference 1

Reference 2

Reference 3

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