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Retailer Application Form
Questions marked by * are required.
1.	Company Name: *
2.	Contact Name: *
3.	Email Address: *
4.	Company Address: *
5.	City, State and Zip Code: *
6.	Company Phone Number: *
7.	Please tell us about your company, and how you would like to integrate LUNA Sandals to your business: *
8.	What is your web address (if you have an online presence)?
9.	Do you have a resale certificate? * Yes No