Company Name

Your Name

Address

City

State

Country

Postal Code

Telephone

Web site address

Email address

Tax Number

Employee Identification Number

Business License Number

I am / we are - check all that apply

| Manufacturers | Wholesalers | Distributors |
| Retail Dealer  | Cue Maker  | Import / Export |
| Other

If other, or for additional information

Products / services you plan to provide us

Minimum order?

 Yes | No | If Yes, amount in USD

Is shipping included in your pricing?

 Yes | No |

How long have you been in business?

 Less than 6 months |  6 months to 1 year|
 1 to 3 years | 3 to 5 years | Longer than 5 years

If you are selling us products, do you you have electronic images?

 Yes | No

Additional information