Shoe-Doodles - Dealer Registration Form

If you would like more information, please fill out the form below and a representative from our Wholesale Department will contact you immediately, regarding pricing and programs.

Please complete the following required information fields.

Information provided is for registration purposes only, and will not be shared with others.

Customer Status	New Customer (never purchased shoe-doodles)
	If you are a new customer, how did you find out about us?

	Current Customer (already placed an order)
Store Name
Contact First Name		Last Name
Shipping Address
Shipping Address 2
City
State/Province/Territory	International Customers - Please select "Not in USA or Canada".
Zip or Postal Code
Country

E-mail
Repeat E-mail
	Please be careful to provide an accurate e-mail address. It is necessary to process your application.

Type of Business		Biz ID#
Day Phone
Evening Phone		Cell Phone
Home Phone		Fax

How Long In Business?	1 Year 2 Years 3-5 Years 5+ Years
Do you currently sell shoe charms?		YES NO
Do you sell rubber clog style shoes?		YES NO
How many stores do you have?
The best time to contact you to open your account?

	Billing Address (if different)
Address
Address 2
City
State/Province/Territory	International Customers - Please select "Not in USA or Canada".
Zip or Postal Code
Country

The Following Information is Required to Access the Wholesale Website

Enter YOUR choice of User ID and a combination of letters & numbers you wish to use as your password. Passwords must be minimum 6 characters (maximum 20 characters). No symbols please. Passwords are case sensitive.

User ID		Password
		Repeat Password