All fields in bold are required.
Company Information
Company Name:
Type of Business:
(Select) Builder Contractor Government Office Landlord Manufacturer Other Plumber Retail Dealer Wholesale Dealer
Buyers Group:
Store #:
Sales Tax ID:
Sales Rep:
(Select) Brit Leggett Josh Reese Kirk Wenger Mark Huggett Lewis Shaum Charles Leggett Brad Harkins Bruce Harkins Mike James Jeremiah James Tom Manning & Associates Jay Saltsman CJS Sales Jordan Simpson None of the Above
Company Address
Address, Line 1:
Address, Line 2:
Address, Line 3:
City:
State:
(Select) Alberta Alaska Alabama Arkansas Arizona British Columbia California Colorado Connecticut Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Manitoba Maryland Maine Michigan Minnesota Missouri Mississippi Montana New Brunswick North Carolina North Dakota Nebraska New Hampshire New Jersey Newfoundland/Labrador New Mexico Nova Scotia Northwest Territories Nunavut Nevada New York Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island South Carolina South Dakota Saskatchewan Tennessee Texas Utah Virgina Vermont Washington Wisconsin West Virginia Wyoming Yukon
Postal Code:
Country:
United States Canada
Main Phone Number:
Secondary or Fax Number:
Web Site:
Primary Contact
First Name:
Last Name:
Email Adress:
Please provide a description of the type of business you have and the brands of the merchandise you sell:
I agree to the terms and conditions governing use of the site and my account, where applicable.
