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Contact Information

* indicates a required field.

*Contact Name

Required

*Email (This will be your logon)

Required
Invalid format.

*Password

Required
Password minimum length must be 6 characters long.

*Verify Password

Required
The passwords do not match.

Select the Retailers

1) you sell to

2) your products are/will be sold.

    Babies R Us
    Bed, Bath & Beyond
    Best Buy
    Circuit City
    Costco
    Crate & Barrel
    Hammacher Shlemmer
    IKEA
    JcPenny
    K-Mart
    Kohl’s
    La-Z-Boy

    Linens N Things
    Office Depot
    Office Max
    Pet Smart
    Pier 1 Imports
    Pottery Barn
    Sam’s Club
    Sears
    Staples
    Target
    Toys R Us
    Walmart

Company Information

The state application forms are populated with this data EXACTLY HOW YOU KEYSTROKE IT in these fields.
Any errors will appear on the actual applications!

DO NOT USE ALL CAPS! (You can edit this information later from within your account if necessary.)

*Company Name

Required

*Address

Required

Address 2

*City/Province/District

Required

*State/Province/District

Required

*Postal Code

Required

*Country

Required

*Phone Number

Required

Fax Number

Mailing Address

Same as Above

Address

Address 2

City/Province/District

State/Province/District

Postal Code

Country

Please complete the following

*Legal Standing

Required

*Date of Incorporation(mm/dd/yyyy)

(mm/dd/yyyy)

State of Incorporation (required in U.S. only)

Federal Employment Identification Number:
(required in U.S. only)

*Principal Officer in Charge

Required

*Title

Required

*Company Owner's Name

Required

*Owner's Title

Required

*Address

Required

Address 2

*City/Province/District

Required

*State/Province/District

Required

*Postal Code

Required

*Country

Required

*1. Has the Company Owner ever been convicted of a felony or misdemeanor, other than minor traffic violations?

No Yes

*2. Have any of the applicants, their spouses, any employee(s), partner(s), joint venture(s), officer(s), or member(s) had any state license, certificate or registration revoked, suspended, denied or otherwise been the subject of disciplinary action by the Bureau of Home Furnishing and Thermal Insulation or any other state Agency?

No Yes

If you answered YES to 1. or 2. above, give particulars of each, including penal code sections and/or criminal case numbers. (This is REQUIRED if either of the above are YES)