D&L
Wholesale Application Questionnaire
Fields marked with '* ' are required
Company Name:
*
First Name:
*
Last Name:
*
Address:
*
Address2:
City:
*
State:
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Postal Code:
Country:
United States
AFGHANISTAN
ALBANIA
ALBERTA
ALGERIA
ANDORRA
ANGOLA
ANGUILLA
ANTIGUA AND BARBUDA
ARGENTINA
ARMENIA
ARUBA
ASCENSION
AUSTRALIA
AUSTRIA
AZERBAIJAN
BAHAMAS
BAHRAIN
BANGLADESH
BARBADOS
BELGIUM
BELIZE
BENIN
BERMUDA
BHUTAN
BOLIVIA
BOSNIA & HERZEGOVINA
BOTSWANA
BRAZIL
BRIT INDIAN OCN TERR
BRUNEI DARUSSALAM
BULGARIA (REP)
BURKINA FASO
BURUNDI
CAMBODIA
CAMEROON
CANADA
CAPE VERDE
CAYMAN ISLANDS
CENTRAL AFRICAN REP
CHAD
CHILE
CHINA (PEOPLE'S REP)
COLOMBIA
COMOROS
CONGO REPUBLIC
COOK ISLAND
COSTA RICA
COTE D'IVOIRE (REP)
CROATIA
CUBA
CYPRUS
CZECH REPUBLIC
DEM REP OF THE CONGO
DENMARK
DJIBOUTI
DOMINICA
DOMINICAN REPUBLIC
EAST TIMOR
ECUADOR
EGYPT
EL SALVADOR
EQUATORIAL GUINEA
ERITREA
ESTONIA
ETHIOPIA
FALKLAND ISLANDS
FAROE ISLANDS
FIJI
FINLAND
FR SOUTH & ANTARCTIC
FRANCE
FRENCH GUIANA
FRENCH POLYNESIA
GABON
GAMBIA
GEORGIA
GERMANY
GHANA
GIBRALTAR
GREAT BRITAIN
GREECE
GREENLAND
GRENADA
GUADELOUPE
GUAM
GUATEMALA
GUINEA
GUINEA-BISSAU
GUYANA
HAITI
HONDURAS (REP)
HONG KONG, CHINA
HUNGARY (REP)
ICELAND
INDIA
INDONESIA
IRAN (ISLAMIC REP)
IRAQ
IRELAND
ISRAEL
ITALY
JAMAICA
JAPAN
JORDAN
KAZAKHSTAN
KENYA
KIRIBATI
KRYGYZSTAN
KUWAIT
LAO PEOPLE'S DEM REP
LATVIA
LEBANON
LESOTHO
LIBERIA
LIBYAN JAMAHIRIYA
LIECHTENSTEIN
LITHUANIA
LUXEMBOURG
MACAO
MACEDONIA
MADAGASCAR
MALAWI
MALAYSIA
MALDIVES
MALI
MALTA
MARIANA ISLANDS
MARSHALL ISLANDS
MARTINIQUE
MAURITANIA
MAURITUS
MEXICO
MICRONESIA
MOLDOVA
MONACO
MONGOLIA
MONTSERRAT
MOROCCO
MOZAMBIQUE
MYANMAR
NAMIBIA
NAURU
NEPAL
NETHERLANDS
NETHERLANDS ANTILLES
NEW CALEDONIA
NEW ZEALAND
NICARAGUA
NIGER
NIGERIA
NIUE
NORFOLK ISLAND
NORWAY
OMAN
PAKISTAN
PALAU
PANAMA (REP)
PAPUA - NEW GUINEA
PARAGUAY
PEOPLES REP OF KOREA
PERU
PHILIPPINES
PITCAIRN ISLANDS
POLAND (REP)
PORTUGAL
PUERTO RICO
QATAR
REUNION
ROMANIA
RUSSIAN FEDERATION
RWANDA
S GEORGIA S SANDWICH
SAINT LUCIA
SAMOA
SAN MARINO
SAO TOME & PRINCIPE
SAUDI ARABIA
SENEGAL
SIERRA LEONE
SINGAPORE
SLOVAKIA
SLOVENIA
SOLOMON ISLANDS
SOMALIA
SOUTH AFRICA
SOUTH KOREA
SPAIN
SRI LANKA
ST KITTS & NEVIS
ST PIERRE & MIQUELON
ST VINCENT & GRENDNS
SUDAN
SURINAME
SWAZILAND
SWEDEN
SWITZERLAND
SYCHELLES
SYRIAN ARAB REPUBLIC
TAIWAN
TAJIKISTAN
TANZANIA (UNITD REP)
TERR COMM OF MAYOTTE
THAILAND
TOGO
TOKELAU
TONGA
TRINIDAD & TOBAGO
TUNISIA
TURKEY
TURKMENISTAN
TURKS & CAICOS ISLES
TUVALU
UGANDA
UKRAINE
UNITED ARAB EMIRATES
UNITED STATES
URUGUAY
UZBEKISTAN
VANUATA
VATICAN
VENEZUELA
VIETNAM
VIRGIN ISLANDS
WALLIS & FUTUNA ISLS
YEMEN
YUGOSLAVIA
ZAMBIA
ZIMBABWE
*
Business Phone:
*
Business Fax:
E-Mail Address:
*
State Tax#:
Website:
Federal ID#:
Indicate the type of business ownership
Select Business Ownership
Corporation
Partnership
Sole Proprietorship
*
Which best describes your business?
Select Business Type
Retail Shop
Manufacturing
Studio
Commission Work
Craft Shows
Education/Instruction
Other
*
Other:
How long have you been in business?
Select Yrs in Business
Planning to open business
Less than 2 years
2-5 years
6-9 years
More than 10 years
*
What aspects of art glass does your business focus on?
Select Business Focus
Panel Work
Lamp Work
Restoration
Hot Glass
Supplies
Mosaics
Other
*
Other:
Where is your business located?
Select Business Location
Commercial space
Residential space
*
What do you spend annually on art glass supplies?
Select Annual Spending
under $1,000
$1,000 to $2,500
$2,500 to $5,000
$5,000 to $10,000
$10,000 to $25,000
over $25,000
*
What percentage of your livelihood is derived by your art glass business?
Select livelihood %
Less than 25%
26 - 50%
51 - 75%
More than 75%
*
Have you purchased with other wholesalers?
Select Yes or No
Yes
No
*
If yes, please name:?
How did you hear about D&L Art Glass Supply?
Select how you found us
Advertisement in publication
Trade Show
Manufacturer referral
www search
Peer referral
Other
*
Please specify publication/manufacturer/search
engine/trade show/etc.:
I am submitting the rest of my documentation...
Comments:
Select submission method
Via fax
Via mail
*
Via fax: 303-442-3429
Via mail : 1440 W. 52nd Ave., Denver, CO 80221
* Enter the image text displayed above
Please note: A complete wholesale application to D&L Art Glass Supply® includes the questionnaire above plus the required documentation mailed or faxed to D&L.