New Retailer Registration

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"*" indicates required fields

Step 1 of 2

Username*

Email*

Password*

Enter Password Confirm Password

Name*

First Last

Company*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Business Type*

Different Delivery Address?

Different Delivery Address

Delivery Address #1

Street Address Address Line 2 City State ZIP Code

Delivery Address #2

Street Address Address Line 2 City State ZIP Code

Delivery Address #3

Street Address Address Line 2 City State ZIP Code

Pricing Based

I am aware that the pricing is based on the delivery address(es) provided and that I am responsible for any extra shipping fees or lumping fees resulting from inaccuracies or changes made by me.

Emergency Contact Name*

Emergency Contact Phone*

Payment Plan*

I understand the first order is handled on a pre-payment plan which means payment will be collected before your order is processed. A secure payment link* will be generated and sent to the above provided email address where you will enter your payment.

*A 4% transaction fee will be added if payment is made by credit card. No charge for wire transfers.

Account Confirmation*

The above information is submitted for the sole purpose of opening an account and I hereby certify the information to be true.

Signature*

Date*

Receive Emails*

I agree to receive Duverger emails

REFERRAL PROGRAM – Which of our current Customers shall we thank for referring you? A $50.00 credit will be issued to the referring Customer once you place your first order. You will also receive $50 off your first order.

Referral Name / Company

Your personal data will be used to support your experience throughout this website, to manage access to your account, and for other purposes described in our privacy policy.