Sell 'Em

Are you ready to carry lugez in your store? Well, please fill out the form below and we will contact you to establish an account. After your account is approved, you will have a unique username and password to purchase on our secured website. If you require terms, please fill out the credit reference section.

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Contact Information:

*Company Name:

*Primary Contact Person(s):

*Address:

*City:

*State:

*Zip:

*Phone:

Fax:

Website:

*E-Mail:

Company Information:

*Distributor(s) You Use:

*Number of Years in Business:

*Number of Locations:

Name of Additional Location:

*Primary Contact Person:

*Address:

*City:

*State:

*Zip:

*Phone:

Fax:

Website:

Industry:

Retail Store	Online Store
Bar	Nightclub
Gentleman's Club	Ladies Club
Home Parties	Liquor Store
Other

Would you like to have your store added to our Store Locator so customers can easily find you?

Yes
No

If so, please provide us, by fax or e-mail, all your stores information. We will need all your stores locations, store hours, phone number, fax number, website, and photo (if available).

*Credit References:*
Company Contact Name:
Address:
City:
State:
Zip:
Phone:

Company Contact Name:
Address:
City:
State:
Zip:
Phone:

Additional Information:

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