Store Information
Store Name
*
DBA
If Applicable
Date Founded
*
-
Month
-
Day
Year
Date
Shipping Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Billing Address (If Different from shipping)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Store Type (check all that apply)
*
Outdoor
Fitness Specialty
Fishing
Boutique/Lifestyle
Resort
Contact Information
Primary Contact
*
First Name
Last Name
Position
*
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Documentation
Tax ID Number
*
Retail License Number
Retail License
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