Retailer Application To become an Authorized Retailer, please complete and submit the following form. You will be contacted shortly!   Date: Company Name: DBA: Address: City, Sate, Zip: Phone: Fax: E-mail Address: Owner's Name: Resale Number: Buyer's Name: Phone / Ext: Years in business: Years at present location: Number of stores: List all locations: Trade References: Name: Fax: City: State: Name: Fax: City: State: Name: Fax: City: State: