new customer registration

fill out this form we will activate your username and password for access to our site. this is a form to validate as a retailer. during peak seasons it may take 2-3 business days for us to respond. we appreciate your parience.
 
Fields with * are required for account activation
 
*retail store:     
*store type: 
if other, please describe your 
business: 
state resale id:


* resale id #: 
 
*company name: 
*contact last name: 
*contact first name: 
*contact email address: 
*confirm email address: 
*contact position: 
*address: 
 
*city: 
*zip code: 
*country:  
*state/province:  
*phone: 
fax: 
url: 
*how did you hear about tag? 
*phone# listed in Yellow Pages 
or local business listing? 		 Yes   No   
 
*username: 
*assign password: 
(case sensitive) 
*confirm password: 
(case sensitive) 
*password hint: 
 
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