DOMESTIC AND INTERNATIONAL CUSTOMER APPROVAL FORM

ONE of THREE
DATE (Month/Day/Year)

BRANDS (Check all that apply)

FLOGG

BADGLEY MISCHKA

CHARLES JOURDAN

FRENCH FOLLIES

PENNY LOVES KENNY

JOE'S JEANS

L.A.M.B.

VIVIENNE WESTWOOD

Corporate Name

DBA Name

OWNER'S NAME

BUYER'S NAME

ADDRESS

CITY

STATE AND COUNTRY

ZIP

PHONE

FAX

EMAIL

WEBSITE

PASSWORD

CONFIRM PASSWORD

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NEXT

DOMESTIC AND INTERNATIONAL CUSTOMER APPROVAL FORM

TWO of THREE
TYPE OF STORE (Check all that apply)

DEPARTMENT STORE

MULTI STORE (4+)

CLOSEOUT

INDEPENDENT

SHOES ONLY

FOREIGN

BOUTIQUE

MAIL ORDER

OTHER

YEAR BUSINESS ESTABLISHED

PRESENT LOCATION SINCE

ARE YOU CURRENTLY DOING BUSINESS WITH TITAN INDUSTRIES, INC.?

No

Yes

IF YOU ANSWERED "YES", WHICH TITAN DIVISION?

COMPARABLE FOOTWEAR LINES YOU ARE CURRENTLY DOING BUSINESS WITH:

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DOMESTIC AND INTERNATIONAL CUSTOMER APPROVAL FORM

THREE of THREE

NUMBER OF STORES YOU OPERATE

LOCATION (Please disclose all locations)

MORE LOCATIONS

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UPLOAD STORE PHOTOS (Minimum 3, up to 5)

PHOTO 1: FRONT STORE (Required)

PHOTO 2: INTERIOR (Required)

PHOTO 3: INTERIOR (Required)

MORE PHOTOS

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SUBMIT GO BACK

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