Dealer Program Request

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Please complete the following dealer request to apply for a My Uptown Pooch dealership. We will review your submission and communicate your account status within the 48 hours of it's receipt.

First Name:
Last Name:
Company Name:
Street:
City:
State:
Zip Code:
Country:
Telephone:
Faximile:
E-mail Address:
Company Website:	(enter as www.mysite.com)
Please Describe Your Business	Select Physical Location No Location Website Only Web and Location
Sales Tax ID Number	(U.S. Business)
Comments:

My Uptown Pooch, P.O. Box 91, Adamsville, RI 02801

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