Application Form

Thank you for your interest in becoming a Country House Collections Online retailer. Please complete the application below in its' entirety.

If you are a current customer be sure and enter your current customer id. Unless otherwise noted, all fields are required.

   
 

Customer Information
   
             
Customer ID:   If a new Customer, Please leave blank
Company Name:
Tax Id:

Billing/Mailing Information - Address must qualify for delivery by United States Postal Service
SALUTATION:
First Name:*
MI:
Last Name:*
Title:
Street Address:*
Street Address2:
City:*
State:*
Zip Code:*
Country:
Phone:*       Ext:  
Fax:      
Email Address:*

Shipping Address Information - This address must be a physical location
   
Shipping Street Address:*
Shipping Street Address2:
Shipping City:*
Shipping State:*
Shipping Zip Code:*

Business Information
Type of Business:*
Years in Business:*
Number of Stores:*
Products you Carry:*
How Did You Hear About Us:*