Retailer Application

If you are a retailer in the U.S. and are interested in selling our products in your store, we invite you to apply for an account. Simply complete the merchant information form below. Once approved, you will receive email confirmation of your account status. In the meantime, if you have any questions about our retailer program, please contact us at 480-429-0787 or email us at sales(at)floppyseat.com. We look forward to working with you to bring Floppy Seat® to your store.

*required information

* Full Name

* Company Name

DBA

* Length of time in business?

* Owner Name

* Business Address

Suite #

* City

* State

* Zip

* Phone

800 #

* Type of store (if you selected other, please describe)

* Business category (Please describe the nature of your business and the types of baby products you sell)

* Please type a UserID you will remember (for online ordering)

* Email Address

Web Address (URL) (do not remove http://)

* Resale tax number

* Do you ship nationwide?

* Do you offer online ordering?

* How did you hear about the Floppy Seat®? (if you selected other, please describe)

* Business Reference 1

*Name

*Address

*Phone

*Business Reference 2

*Name

*Address

*Phone

Please add additional comments here

* I/We certity that all statements made herein are true and accurate. I/We authorize Floppy Products, Inc. to make any and all inquiries necessary of the above listed business reference relating to this application, and do grant permission to the above listed business references to release such information as may be requested by Floppy Products, Inc.

Date: Thursday 23rd 2013f May, 2013

*by checking this box, you are giving your signature to this form.

* title