Black Star Jewelry Importers

Reseller Application

Wholesale Account Request Form

First Name:
Last Name:
Company:
Tax ID: (where applicable)
Address:
City:
State (if US):
Zip/Postal Code:
Country:
Phone:
Fax:
E-Mail:
Ship to same?:	Yes No
Ship to First Name:
Ship to Last Name:
Ship to Company:
Ship to Address:
Ship to City:
Ship to State (if US):
Ship to Zip/Postal Code:
Ship to Country:
User Name:
Password: (6 to 12 characters)
Repeat Password:
How you heard about us: