EmailMe Form - Request a Wholesale Account

Name

First Last

Job Title/ Function:

Phone

### - ### - ####

Fax:

### - ### - ####

Email:

Web Site:

Name of Company / Business:

Name of boutique, spa, etc, if different from Company / Business Name:

Tax ID Number or FEIN Number:

Resale ID Number:

Contact Name / Store Manager:

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone:

### - ### - ####

Fax:

### - ### - ####

Email:

Primary Business Category:

Other:

Location:

Other:

Location Type:

Square Footage of Retail Shop:

Number of Location(s):

If more than 1 location, describe any additional locations using the criteria above:

Date Retail Shop Opened:

MM / DD / YYYY

If Not Yet Open, Opening Date:

MM / DD / YYYY

List other retail outlets or major stores near your location:

List Products and Brands That You Carry:

Billing Address:

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Shipping Address (Leave empty if same as billing address):

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

How did you hear about Oscar Newman?