* Required


Company Information

Company Name* :

Please select one*

Corporation
LLC
Sole Proprietorship
Non-profit Organization
Partnership

Resale License #: (Please fax or email a copy of your resale license)* :

Principle Owner(s)* :

Buyer Name:

How many years under current ownership?* :



Contact Information

Billing Address* :


Shipping Address* :


Phone Number* :

Fax Number :

Email Address :



Business Information

Retail Website Address : (if applicable)

Business Type (Check all that apply)*

Physical Retail Store
Website
Corporate Gifts / Special Events
Catalog / Mail Order
Wholesale / Distributor
Importer / Manufacturer

Type of store(Check all that apply)*

Gallery (Retails $100 and higher)
General Gifts (Retails $30 - $99)
Souvenir (Retails $29 and lower)
Home Design / Furniture
Jewelry
Other

How did you hear about us* :


Do you attend trade shows? If yes, please list trade shows attended :

Would you like to be contacted by your local Dynasty Gallery Sales rep?*

Yes
No



Thank you for your interest in becoming a Dynasty Gallery retailer.
If you would like to order online, you must first register for web access. Click here.

Dynasty Gallery reserves the right to decline applications without notice.

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