Basic Information
First Name (required)

Last Name (required)

Email Address (required)

Telephone Number

Company Information
Company Name (required)

Company's Legal Name (required)

Company's EIN/FIN/Tax ID/VAT (required)

Resale License Number (required in the United States)

How many years has your company been in business?

Website Address (required)

Buyer Information
Buyer's First Name

Buyer's Last Name

Buyer's Email Address

Buyer's Telephone

Logistic Information
Logistic's First Name

Logistic's Last Name

Logistic's Email Address

Logistic's Telephone

Accounts Receivable Information
Accountant's First Name

Accountant's Last Name

Accountant's Email Address

Accountant's Telephone

Store Information
Footprint
---Independent - One storeRegional - Stores in more than one stateNational - Stores across the USDirect - Web or Catalog OnlyE-commerce WebsiteE-commerce Website & Brick & MortarInternational - Non-US locations
Annual Volume
---less than 1,000,0001,000,001 - 5,000,0005,000,001 - 20,000,00020,000,001 - 50,000,00050,000,000+
Number of Stores
---0 - 56 - 1011 - 1516+
What lines do you currently carry? Be specific

Do you intend to carry our merchandise in multiple locations?
---Yes, we intend to carry 619 in multiple places.No, we only intend to carry 619 in one location.
If you intend to carry our sixnineteen in multiple locations, how many and where, exactly?

Tell us a little (or a lot) more about your shop and why you think sixnineteen is a good fit for your store.

Social Media Information
Facebook URL or Handle

Instagram URL or Handle

Twitter URL or Handle

YouTube URL or Handle

Pinterest URL or Handle

Message to sixnineteen

Who should we thank for referring you to sixnineteen?
---sixnineteen Team MemberFriend or FamilyHappy CustomerEditorial PressSocial MediaInternet SearchTradeshowProduct ResearchOther
I agree to abide by the Wholesale Terms & Conditions set forth.