I. PERSONAL IDENTIFICATION

First Name (required)

Middle Name (required)

Last Name (required)

Title (required)

II. RETAIL LOCATION INFORMATION

Name of Business (required)

No. of Employees: (Optional)

No. of Customers: (Optional)

Tex ID: (required)

Type of Bus.Ownership:
S-CorpLLCC-CorpLLPPartnership


Mailing Address (if different): (Optional)

Address, City, State, Zip (required)

III. RETAIL CONTACT INFORMATION

Phone: (required)

Fax: (Optional)

Website: (required)

Purchasing Contact: (required)

Name: (required)

Ext: (required)

Email: (required)

Billing Contact: (required)

Name: (required)

Ext: (required)

Email: (required)

IV. RETAILER OVERVIEW

Type:
ChainIndividualOnline
Store No. (required)



Location:
Main St.Strip MallMall


Retailer Specialty: (required)

No. of Locations: (required)

Additional Services Offered: (required)