hen and barley press : dealer application

Please complete the Dealer Application below, and a wholesale price list will be faxed, e-mailed or mailed upon request.

First Name:
Last Name:
Store Name:
Type of Business:	Sole Proprietor Partnership Corporation LLC
Type of Store:	Retail Storefront Homebased Internet
Tax ID Number:
Years in Business:
Store/Shipping Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
Email:
Website:
Do you have the ability to pay with credit card rather than terms?:	yes no
How did you hear about us?:

Please call us (414-559-8980) or e-mail us for retail information.