Dealer Registration Form

All fields with a * are required.

Company Information

Company Name:* Your Title:*
First Name:* Last Name:*
E-mail:*    
Phone Number:* Fax Number:*
Type:*
Tax ID Number:* Years In Business:*
Num of Locations:*    

Billing Address

Address Line 1:* Address Line 2:
City:* Province/State:*
Country:* Postal/Zip Code:*

Shipping Address

Address Line 1: Address Line 2:
City: Province/State:
Country: Postal/Zip Code:

Application For Credit

By completing the information below, I wish to apply for credit and permit Personalized Gems to acquire information from the bank and trade references provided below, and agree to abide by the credit terms if so granted.
Bank Reference
Bank Name:* Account Number:*
Address:* City:*
Province/State:* Name of Contact:*

Industry References

Company Name:* Address Line:*
City:* Province/State:*
Name of Contact:*    
 
Company Name: Address Line:
City: Province/State:
Name of Contact:    
Acknowledgment Of Duly Authorized Officer
I wish to be an on-line exclusive distributor in my trading area as identified by Personalized Gems. I agree to the one time set-up fee of $250 per location and authorize the above noted credit card to be charged for this and all future purchases from Personalized Gems.
Exclusive Distributor:*
 
Would you like to display your e-mail address as part of your contact information on this website?*