*  Email Address:
First Name:
Last Name:
Address:
Address (line 2):
City:
State:
Zip Code:
Country:
Work Phone
Fax
Store Name
Title
Type of Store (children's wear, gift, juvenile products, footwear, catalog, e-commerce)
Children's Wear/Accessory Domestic Lines Carried
Children's Wear/Accessory European Lines Carried
Footwear Lines Carried
Juvenile Product Lines Carried (hard goods, soft goods)
Gift Lines Carried
Resale License Number/Federal Tax I.D.
Website Address
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