MERCHANT SIGN-UP     DATE: __________________

BUSINESS NAME:

CONTACT NAME:

TITLE: 

STREET ADDRESS:

ADDRESS:

CITY:

STATE:

ZIPCODE:

BUSINESS NUMBER:

FAX NUMBER:

EMAIL:

WEBSITE:

COMMENT:

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Please Fax to (319) 845-2002 with a Faxed copy of your Resale Certificate (Tax Permit), and we will email you a Reseller ID and password to our Merchant Site.

Questions? Call us at (319) 845-2000