Your E-mail address:        
Your Webpage Address:      
Registered business Name:    
Address:   
City:   State/Province
Zip/Postal code:Country
telephone: Fax Number: 
Choose One: Propriertorship Partnership Corporation
Are premised used solely for business purposes? Yes No
Building is: Owned Leased -- Length of Lease: 
Incorportion Date: # of outlets: Tax Number 
Bank:Acct:
Officer Name:
Address: 
Telephone: 
Name of Owner, Partners, Principles:
Name of Store Manager: 
Name of A/P Clerk: 
Nature of Business: 
Business Trade Reference: (note: Must have complete name, phone and fax number or toll free fax number)

Order Shipped via UPS ground/cheapest is acceptable?
 Yes No


Name:_______________________Signature:__________________Date:_________

Be sure all the information is correct, then PRINT & Fax IT ASAP to (888) 872-5742
 for U.S. and (800) 661-7400 for Canada.