Verlaque Direct Application

(INFORMATION NEEDED TO APPLY TO BECOME A VERLAQUE DIRECT STOCKIST)

Name of shop:

Business name (if different to above):

Registration number:

VAT number:

Postal address:

Physical delivery address:

Contact person:

Telephone number:

Fax number:

Mobile number:

Email address:

Attach your store logo (recommended). Paul - add a tick box saying "We give Verlaque permission to display our logo, as a stockist, on this website."

Attach photo of yourself (optional).

Attach photo of your shop (optional).

Tell us a little about your business; the types of products you stock, the customers you serve, what special things you do to help sell your products.