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Become a Houseworks Dealer

Please provide the following information, and we will begin the process of registering you as a Houseworks dealer. You will be contacted by phone or email, within 2 business days, by a Houseworks representative. Thank you.

Date:
Name of Business:
First Name:
Last Name:

Business Address:
City:
State:
Zip:
Country:
Business Contact Phone:

Preferred Shipping Method:		UPS FedEx Other

Shipping Address Is A:		Business Address Residential Address

Shipping Address:
City:
State:
Zip:
Country:

Alternate Phone:
Fax:

Your Website:

Email Address:
Confirm Email Address:
Password for This Account:
Passwords should be 6-10 lowercase letters or numbers. No spaces.

This is in regard to :		Corporation Partnership Proprietorship

Type of business: (select as many as apply)		Storefront Internet Manufacturer Artisan Distributor Shows

Payment type:		VISA MasterCard Discover American Express Check

		Transactions Protected By:
Credit Card #:
Expiration:
CVV:
Name on Card:

Number of Stores:
Year Business Started:
Tax Number:
Business License:

Comments: