User Registration

* Required field

Name *

Username *

Password *

Confirm Password *

Email Address *

Confirm Email Address *

User Profile

Are you a current customer? *

What is your customer number? (optional)

What is the name of your company? *

What is the name of the main contact person? (optional)

Please add me to your email list (optional)

Address 1: *

Address 2: (optional)

City: *

State *

Postal / ZIP Code: *

Phone: *

Fax (optional)

Web site: (optional)

Business License Number (optional)

Reseller Permit Number (optional)

Names of people allowed to buy (optional)

Different Billing Address (optional)

Check if Billing Address is Different

Billing Address 1 (optional)

Billing Address 2 (optional)

Billing City (optional)

Billing State (optional)

Billing Postal Zip Code (optional)

Billing Country (optional)

Bill Phone Number (optional)

Have you faxed the application form (optional)

Yes No

Have you faxed the state tax form (optional)

Yes No

Have you faxed a copy of your business license (optional)

Yes No

Have you faxed a copy of your reseller permit (optional)

Yes No

Did you submit other forms (optional)

Are you a floral shop (optional)

Yes No

Are you a gift company (optional)

Yes No

Other Company Type (optional)

Do you have a storefront (optional)

Yes No

Do you have a warehouse facility (optional)

Yes No

Is this a home business (optional)

Yes No

Do you have a webstore (optional)

Yes No

Do you have anything to add? (optional)

How did you hear about us? Please include all that apply: Online Ad, Internet Search, Email/Direct Mail, Referral, Print Ad, Tradeshow, Other: (optional)

OFFICE USE ONLY: Customer Code (optional)

OFFICE USE ONLY: Web Salesman Code (optional)

10022

OFFICE USE ONLY: Office Salesman Code (optional)

OFFICE USE ONLY: Web Pricing (optional)

A B C

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