Authorized Retailer Application Form

*First name

*Last name

Company

*Email

*New Password (what you will use to login into the site in the future)

*Phone number

Alternate phone

Fax

Website

Sales tax ID

Federal tax ID

Rep/Showroom name

*About your store

*How did you hear about us?

*Do you want to be listed on our website map?

*Which address should be used on website map? (or no if not listed)

Billing and/or Shipping Address

*First Name

*Last Name

*Address

No shipments to PO or APO Boxes

*City

*State (Please use 2 digit state code)

*ZIP Code

*Phone

Ship to a different address

Exclusivity and Territory Protection

We reserve the right to "protect" and limit sales to customers and customer types in certain geographic areas to protect existing specific customers, and to avoid being over represented in a certain sales area. This will be reviewed on a case-by-case basis.

Feed on the Word, Inc.

470-266-9914

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Mixed Dinnerware Cases

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