Distributor's online registraion

* - Required Feilds

Personal
 First Name:  *
 Last Name:  *
 E-Mail Address:  *
E-Mail will be used as
your login in name.


Company Information
 Company:  
 Choose Your Store ID:  *
 List on distributors map: No  Yes
 Price Option: Show Prices  Hide Prices
 Markup Price %:  
Store ID - please avoid spaces.
Markup price - if you are not sure about your initial price structure, just leave it at 120 - you can adjust it later.


Address
 Street Address:  *
 Apt/Suite:  
 Zip Code:  *
 City:  *
 Country:
 State:  *
This address information will be displayed as your contact information at your online store.


Contact
 Telephone Number: () *
 Fax Number:  


Password
 Password:  *
 Password Confirmation:  *