Miss Lillian’s Retailer Application Form | Miss Lillian's NO WAX Chock Paint

Thank you for your interest in becoming a Miss Lillian’s NO WAX Chock Paint Retailer. Please complete this application in full. We will review your information provided and check to see if there is availability in your area. Please provide the physical street address (No P.O. Boxes please) of the location of your business. MUST provide either a Facebook Business Page or Website. Please allow up to 2 business days for review!

Please Complete the Retailer Application Form

* indicates required

Email Address *

First Name *

Last Name *

Phone Number *

Your Business Name *

Store Type *

Store Front
Vendor in Market/Antique Mall

If Vendor – Name of Antique Mall/Market *

Please Describe Store Hours and Days Open *

Referred by:

Business Location Address *

Address Line 2

City

State/Province/Region

Postal / Zip Code

Country

Shipping Address *

Address Line 2

City

State/Province/Region

Postal / Zip Code

Country

Do you currently carry another Paint Line? *

If YES, which Paint Line do you currently carry?

Please Provide a Facebook Page or Website URL: *

Tell us more about You and Your Shop! *