Retailer Account Application

Please fill in the form completely to expedite processing.

Your Contact Information
Your Name:
	We may wish to contact you for additional information about your application. Please provide a valid email address below.
Your Email Address:
Company Information
Store Name:
Street Address:
Store City:	State: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Zip:
	Mailing Address (if different from above)
Mailing Address:
Mailing City:	State: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Zip:
Store Main Phone #:
Fax #:
Sales Tax Permit Number:
	Copy of Sales Tax Permit needs to be mailed or faxed to Lone Star.
Owner Information
Owner(s) First Name:	Last Name:
Owner's Home Address:
Owner's City:	State: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Zip:
Owner's Home Phone #:
Owner's Cell #:
Check Writer's Information
Check Writer's First Name:	Last Name:
Check Writer's Drivers Lic.#:	State: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   DOB:
	2nd Check Writer's Information (Optional)
2nd Check Writer's First Name:	Last Name:
2nd Check Writer's Drivers Lic.#:	State: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   DOB:
Contact Information
1st Contact Name:
(Optional) 2nd Contact Name:
Contact Methods:	PhoneFaxEmailMail
Other Information
Two pet industry references:	Please include names & phone numbers.
Do you have a retail store with signage?:	YesNo
Size of Store (sq. ft.):
Number of Employees:
Store Hours:
Store Image:	Please provide .jpg picture of storefront and signage. We do not deliver to Residential Areas.
P/O Required?:	YesNo
Fax Invoices?:	YesNo
Email Invoices?:	YesNo
Fax Statements?:	YesNo
Email Statements?:	YesNo
Lone Star Pet Supply's terms of sale are Collect on Delivery. This is not an application for credit. This form and a copy of the Sales Tax Permit must be on file at our office before we can sell to you.