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USERNAME / PASSWORD
*Username
  *Password

(password must be 6-8 characters)
*Confirm Password
 

-ACCOUNT INFORMATION-
*Company Name:
*First Name:
*Last Name:
Phone:
Fax:
*Email:
*Confirm Email:

BILLING INFORMATION
*Billing Address: *NOTE:
Your Billing information
will be used for shipping
unless otherwise specified below
*Billing Address Cont.:
*Billing City:
*Billing State:
*Billing Zip Code:

SHIPPING ADDRESS Same as Billing Address
*Shipping First Name:
*Shipping Last Name:
*Shipping Address:
*Shipping Address Cont.:
*Shipping City:
*Shipping State:
*Shipping Zip Code:

Business Profile  
Please fill in any distributior account numbers you have

 
Tucker Rocky Distributing  
J&D Walter Distributors, Inc.
J&M Corporation
Sammy Tanner Distributing
 
  I will accept email from Arai.