Application to Become a Registered Dealer of Karen Benson Miniatures

Name
Position
Owner's Name (if different)
Business Name
Registration (Tax) Number
Business Address
State Zip Code
Mailing Address (if different)
State Zip Code
Telephone
Fax
Email
Website
Type of Business (check all that apply) "Brick & Mortar" Store Website eBay
Years in business

TERMS: Credit cards, Paypal, Checks/Money Orders or Proforma Invoice.

The undersigned hereby certifies that he or she is duly authorized to sign this application, that the information given in this application is true and correct to the best of his or her knowledge and that the Applicant/Buyer hereby agrees to the foregoing terms and conditions.

I have read and agree to all terms printed on this application: Yes No