Store Name (if different)__________________________________________________________

Contact:_________________________________________ Title __________________________

Email Address: (required for wholesale price list - Please print very clearly!

           ________________________________________________

Telephone _________________________________________  Fax __________________________________________

State Sales Tax#, Re-Seller's ID, etc: _______________________________ or Fed. ID# ____________________________

Name of Owner ______________________________________________________________

Accounts Payable Contact if other than owner:

Name _______________________________________          Phone ______________________________

Proprietorship?  Yes No      Partnership?  Yes No                Corporation?   Yes No

How Long in Business? ________________ How long at this address? _____________

Are there specific themes you're looking for in quilting patterns (contemporary, traditional, art quilt, modern quilt, cats, lighthouses, tea/coffee, clothing/wearable art, children's, etc.)  _________________________________________________

_____________________________________________________________________________________________________