Company
Store Name
Resale Number
Store Owner 		Address of Store Location
City
State
Zip


Name of Buyer
Phone contact for Buyer
Email contact for Buyer
Fax contact for Buyer
Billing Address [If different than above]
City
State
Zip
Billing Phone
Billing Fax
Billing Email
Billing Contact Person


Shipping Address [If different than above]
City
State
Zip
Shipping Phone
Shipping Fax


Store Classification

if other, please specify:
Location

if other, please specify: How did you hear about Zulugrass jewelry?

The Leakey Collection prefers payment before shipping. Please enter your preferred method of payment below. The Leakey Collection does not process payment until one day before shipping.

Method of Payment:

Card type

Name as appears on card

Credit Card Number

Expiration Date

Security Code

Kindly send checks to:
The Leakey Collection
336 Otero
Newport Beach, CA 92660

Call for additional payment information -- 877 532 5392 ext. 120

TLC is developing new products. Help us serve you better by sharing with us the top three selling products, or lines in your store:

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