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Please fill in the information below. A Designer Blinds Representative will contact you.

	Name
	Company Name
	Street Address
	Address (cont.)
	City
	State
	Zip/Postal Code
		USA
	Phone
	FAX
	E-mail
	Website URL

Have you ever had an account with Designer Blinds before?

Yes No

If yes, what was your previous account number and account name?

Previous account number:

Previous account name:

Are you currently in the window covering business?

Yes No

If so, what brands do you sell and who are your current suppliers?

What type of business will you be operating?

a store
a shop-at-home service
both
other please specify:

What is the best time for Designer Blinds to contact you?

Where did you hear about Designer Blinds?

Comments or suggestions...

Upon submitting this form you will be able to download a Designer Blinds Credit Application, and Nebraska Form 13.
These forms must be completed in order for you to become a Designer Blinds dealer.