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Store Owner's Name

First Name

Last Name

Buyer's Name (if other than store owner)

First Name

Last Name

Store Name(s)

Email Address

Store Phone

(###)

###

####

Mobile Phone

(###)

###

####

Resale Number

State for Resale Number above

Date Store Opened

Store Website, Facebook page or Blog

Store Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Shipping Address (if different than store address)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Billing Address (if different than shipping)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How did you find out about my work?

Gallery or Store Style

Other Jewelry Lines Carried at Your Store

Tradeshows You Attend and Seasons