Application to Become an Independant Retailer

We appreciate your interest in the Floppy Seat®;, the desire to retail Floppy Seat®; in your store and for taking the time to contact us. Please fill out the application below in its entirety. Our company's objective is to process your application expeditiously and hassle-free.

You will be notified by e-mail from our office regarding the review of your application.

Thank you.
* Name of applicant
* Name of business
DBA
* Length of time in business?
* Owner Name
* Business Address
Suite #
* City
* State
* Zip
* Phone
800 #

* Type of store
(if you selected other, please describe)

* Business category
(Please describe the nature of your business and the types of baby products you sell)
* Please type a UserID you will remember (for online ordering)
* Email Address
Web Address (URL)
(do not remove http://)
* Resale tax number
* Do you ship nationwide?
* Do you offer online ordering?
* How did you hear about the Floppy Seat®?
(if you selected other, please describe)
* Business Reference
 (1)
* Name
* Address
* Phone
* Business Reference
 (2)
* Name
* Address
* Phone
Please add additional comments here
*


I/We certity that all statements made herein are true and accurate. I/We authorize Floppy Products, Inc. to make any and all inquiries necessary of the above listed business reference relating to this application, and do grant permission to the above listed business references to release such information as may be requested by Floppy Products, Inc.

Date
Wednesday 23rd of July, 2008

*
by checking this box, you are giving your signature to this form
* title
*required information

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