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

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):

Customer Testimonials