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