Credit App

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Account

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Store Name*

Store Address*

City*

State*

Zip*

Buyer Name(s)*

Buyer Phone*

Buyer Email*

Store Phone*

Store Fax*

Store Website*

Store Type*

Years in Business*

Multiple Stores?*

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Tax Resale License #*

How did you hear about us?*

Please list the other jewelry brands you currently carry below*

List stores you consider to be a distribution conflict below.*