Please provide the following website ownership registration and contact information:

Who is the legal owner of the website & program:*
Individual
Business
Corporation
Provide the owners legal address & information
Title
Organization
Street Address	*
Address (cont.)	*
City	*
State/Province	*
Zip/Postal Code	*
Country	*
Work Phone	*
Cell	*
E-mail	*
URL
Contact Person #1	*
Contact Person #2

Please provide the name and address of your main retail store and location.

Store Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail
URL

If you have a second retail location and would like it featured on your new website please complete the information below:

2nd Store Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail
URL

 

Choose one of the following purchase options:

INTRO SPECIAL $785.00 plus $29.95/mo 2yr contract
Custom Website $3995.00 $29.95/mo 2 yr contract
Webmaster Template $1995.00

How would you like to pay for your purchase:

Credit Card
Will send a company check
Bank wire transfer
Other - please contact me

 

Please provide the following credit card payment information:

	BILLING
Credit Card	VISA MasterCard American Express Discover
Cardholder Name
Card Number
Expiration Date

	Credit Card Billing Address:
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

Tell us about your company

Retail Jewelry Storefront, single location
Retail Jewelry Storefronts, 2 -4 locations
Retail Jewelry Storefronts, 5 - 10 locations
Retail Storefront - other
No Storefront, mail order distribution
No Storefront, Internet company
No Storefront, work out of my home
No Storefront, conduct private party shows
other

Is your company listed with the Jewelers Board of  Trade (JBT)?

Yes - we are listed with the JBT
No - we are NOT listed with the JBT
No - new company start up, not yet listed, but will be

IMPORTANT: Most all suppliers, wholesalers and manufactures in the Jewelry Industry, will not do business with you unless you are listed with the JBT. A "listing" of your business with the JBT is FREE.

Additional Information or Comments

If you are paying be credit card, enter the amount that we are authorized to charge and process for your purchase: