Become A Retailer

Retailer / Credit Application

Please fill out the information below to submit your application. All fields are required.


Type of Business (Please check one or more): RetailWebCommercialDesigner

Retailer Setup Information:

Corporate Name:

Phone Number:

Address:

Fax Number:

City:

State:

ZIP Code:

Website:

Federal ID#:

State Incorporated:

Years Incorporated:

Buyer Contact:

Phone Number:

Email:

Fax Number:

Accounts Payable Contact:

Phone Number:

Email:

Fax Number:

Billing Address:

City:

State:

ZIP Code:

Payment Terms Requested:

Please check one: Credit Card (Visa/MC Only)PrepayNet 30 Terms

Please List Five Trade Credit References

(1) Company Name:

Email:

Address:

City:

State:

ZIP Code:

Account Number:

Phone Number:

Fax Number:

(2) Company Name:

Email:

Address:

City:

State:

ZIP Code:

Account Number:

Phone Number:

Fax Number:

(3) Company Name:

Email:

Address:

City:

State:

ZIP Code:

Account Number:

Phone Number:

Fax Number:

(4) Company Name:

Email:

Address:

City:

State:

ZIP Code:

Account Number:

Phone Number:

Fax Number:

(5) Company Name:

Email:

Address:

City:

State:

ZIP Code:

Account Number:

Phone Number:

Fax Number:

Product Delivery Preference:

Please check one or more: Drop Ship direct to customersDirect to StoresDistribution Center

Ship to Address:

City:

State:

ZIP Code:

Shipping Confirmation Email:

Phone Number:

Fax Number:

Preferred Freight Carrier: