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Retailers' Registration Form

 
All that is required to establish an account is to submit the information requested below. This information will be used verify your credentials. We also request that you purchase five frames representing the most popular colors in two sizes, to show your potential patients, so that they can touch and feel the product, and choose the color most suited for their baby.


 
Full Name


Business DBA


Business Address


City


State / Province / Region


Postal Code


Country


Business Phone


Business Fax


E-mail


Comments



Credit Card


Expiration
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NOTE: your password will be stored using one-way encryption. This means that if you lose your password, there will be no way to recover it. In that event, you will be required choose a new password.

Username


Password


Confirm










P.O. Box 349 Burlingame
California 94011, USA
Tel: 650.340.1773 Fax: 650.340.1774
Email: click here





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