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CONTACT INFO

Please enter name of business, city and state as shown on Business Permit (Not Sales Tax License) in the 'Contact Info' section.

Comapny Name

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Fax

STORE FRONT DETAILS

State Sales Tax Number

Number of Needles

Number of Heads

Embroidery Equipment (Brand/Model)

Name of Commercial Distributor Equipment Was Purchased From

List of Commercial Distributors You Currently Have Accounts With

(Please seperate each with a comma)

Website

Is Your Billing Info the same as Contact Info Above?

Yes

BILLING INFO

Billing Contact Name

Billing Address Line 1

Billing Address Line 2

Billing City

Billing State

Billing Zip Code

Billing Phone

Is Your Shipping Info the same as Contact Info Above?

Yes

SHIPPING INFO

Shipping Contact Name

Shipping Address Line 1

Shipping Address Line 2

Shipping City

Shipping State

Shipping Zip Code

Shipping Phone