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Re-Seller Application

* Fields are required
Legal Business Name*:
Legal Owner Name(s)*:
In business since (mm/dd/yyyy):
Description of your business:

* I would like to have my business listed as a Floclaire Retailer at www.floclaire.com
Yes
No
Shipping Address*:
City*:
State/Province*:
Zip/Postal Code*:
Shipping Country*:
Billing Address (if different than above):
City:
State/Province:
Zip/Postal Code:
Billing Country:
Store Manager or Contact*:
Others authorized to place orders:
Phone (xxx)xxx-xxxx*:
Fax (xxx)xxx-xxxx:
E-mail Address*:
Web Site (where applicable):
Date (mm/dd/yyyy):