Form of Business:
Proprietorship    Partnership    Corporation    Limited Liability
      State:     Tax ID / Resale Number:

Billing Information:
Business Name:
Address Line 1:
Address Line 2:
City, State, Zip: 

Ship To (If different):
Store Name:      
Address Line 1:
Address Line 2:
City, State, Zip: 

Shop Phone:
            Fax:

E-mail:

Store Contacts:
Owner    Manager    Buyer    Other
      Name:

Owner    Manager    Buyer    Other
      Name:

Under Current Ownership Since: (year)
At the Current Address Since: (year)

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