NEW CUSTOMER SIGNUP (Retail stores only)

Store Name
Address 1 *
Address 2
City *
State *
Zip/Postal Code *
Phone Area Code *
Phone *
Fax Area Code *
Fax *
Store Owner Name *
Manager/Buyer Name *
Website
Primary Distributor *
Secondary Distributor *
Are you a...
Petland Store?		Yes No
Nexpet Member?		Yes No
PSP Store?		Yes No
PSP Store Number *:
* How did you hear about Blue Ribbon Pet Products?
		Manufacturer:   Internet:           Print Ad:           Store Owner:
Other (Please describe)
E-mail *
Confirm E-mail *
Password *
Confirm Password *

* = Required fields

IMPORTANT: For your application to be processed, you must fax a copy of your State Resale Certificate to (631) 864-1291.