WHOLESALE ANDARA  ACCOUNT
Lady NellieTM
WHOLESALE ANDARA ACCOUNT APPLICATION

Initial minimum purchase:   $150.00  (No minimum required on second purchase)
FULL NAME:
First                           Middle Initial                  Last
ADDRESS:
Street Address
City,                                State (Province)                  Zip Code
Country
Home Phone:
BUSINESS NAME:
the name you are doing business under
RESALE TAX ID:
BUSINESS ADDRESS: (if
different from above)
Street Address
City,                                State (Province)                  Zip Code
Country
Business Phone:
Internet Store
TYPE OF BUSINESS
Please check boxes that apply:
Website Address
Retail Store (Physical Store)
Email Address:
Copyright © 2009, 2010 Lady Nellie.com. All Rights Reserved.
Lady Nellie.com  
Home of the Andara Crystals