Company Name:
Company Address 1:
Company Address 2:
City:
State: -- Select One -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Country:
Federal Tax ID#:
Sales Tax Permit#:
Type of Business: (Check all that apply) Retailer
Please provide a brief description of your company and type(s) of product(s) sold:
Do you sell branded or logo'd merchandise?: Yes No
* Contact Name:
Contact Title:
Phone #:
Fax #:
* Email:
How did you learn about the Earbud Yo-Yo®?:
Are you interested in distributing a branded or logo'd Earbud Yo-Yo®?: Yes No
Are you interested in bundling the Earbud Yo-Yo® with one of your existing products?: Yes No
Where do you plan to market and sell the Earbud Yo-Yo®?:
* Security Code: (NOT case sensitve)
Please Enter Code:
