Register for a Merchant Account

Logon Information
Username*
Password*
Retype*

User Information
First Name*
Last Name*
Email*
Phone*
Fax

* Indicates mandatory fields
Merchant Information
Business Name
State TaxId or SSN
Website (if any)
Mailing Name*
Mailing Address*
City*
State*
Country*
Zip or Postal*

Email Options
Would you like to be notified of special deals, closeouts and general announcements?
Do you want to be notified of new products listed?
Do you want to be notified when a product goes out of stock or in stock?

Other Information
How long have you been in business? Under 1 year 1-2 Years 3-5 Years 5+ Years
What type of business do you own? Retail Storefront Online Store Other
What type of products are you interested in?*
How did you find out about Brybelly?*
Sign-up code (if you have one)
How do you plan on selling our products or using our products?*

Additional Comments:
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