NOTE: This is not a credit application. We ask potential dealers to qualify for wholesale prices by completing and returning this form with supporting materials. By utilizing this process, we assure our dealers that they are not competing with consumers masquerading as businesses. We regret that this action has become necessary but have found that the effort is appreciated by legitimate retailers.

Business Name:

Owner's Name:

Your Name (if different from owner):

Title:

Street Address:

City:

State or Province:

Zip or Postal Code:

Country:

Shipping Address (if different):

Check here if business location is a residence: q

Business Phone Number:

Check here if same as home: q

Business Fax Number:

Toll-Free Number:

Email address:

Website:

Business ownership: (check one)

q Sole Proprietorship

q Partnership

q Corporation

q Non-Profit Corporation

Business type: (check all that apply)

q Retail Store q Mail Order Catalog q Online Catalog q Mobile Shop*

*must provide photograph

q Other (please specify):

Business location: (check one) q Rural q Suburban q Metropolitan

Approximate square footage:

Length (if mobile unit):

Products Sold/Services Offered:(check all that apply)

Do Sales Representatives call on you? q Yes q No

Please provide the name and phone number of one of your current Sales Representatives:

Sales Representative Name:                                        Phone:                  Email Address: 

Major line(s) they represent:

Please list three of your principal suppliers (manufacturers and/or distributors):

    Company           Contact Name         Phone Number        Email

1.

2.

3.

Do you have a listing in the Yellow Pages? qYes qNo

Do you advertise in local or national publications? q Yes qNo

If yes, please include a copy of an advertisement, include name and date of publication.

Do you make the majority of the buying decisions? q Yes qNo

If not, who does?

Buyer's name:                              Phone number:          Email:

Copy of: City or County business license

Copy of: State sales tax/resellers permit

Also, please include:

    Catalog, if applicable

    Federal Employer's Identification Number

    Photograph of store, mobile unit or business sign (PHOTO REQUIRED IF BUSINESS IS A MOBILE UNIT)

    Business card

Signature:                                                     Date:
 
 
 
 

Return to: Glenbrook Creations
           3523 Tallyho Ct.
           Davidsonville, MD 21035 USA

Phone:    (410) 798-5474
Fax:      (888) 831-0881 or (410) 798-5475 (Intl)
Email:    Sales@GlenbrookCreations.com