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:
Type the characters shown in the image for verification: