Wholesale Dealer Application

Applicant

First Name

Last Name

Job Title

Business Phone

Mobile Phone

Company / HQ

Company Name

Trade Names

Website URL

Additional URLs

Address

is Delivery same as Invoice?

NoYes

Invoice Address

Delivery Address

City

Delivery City

State / Prov.

Postal Code

Delivery State / Prov.

Delivery Postal Code

Business Contacts

Manager

Is Applicant

NoYes

First Name

Last Name

Mobile Phone

Business Phone

Owner

Is Applicant

NoYes

First Name

Last Name

Mobile Phone

Business Phone

Accounts Payable

Is Applicant

NoYes

First Name

Last Name

Mobile Phone

Business Phone

Please provide the first name, last name, and email address for each buyer that will need access to our ordering website.

Details

Upload photos of your store. Press [Ctrl] or [CMD] and select up to 5 files. Total of all photos is limited to 100 MB. Exterior and interior photos are required.

Generate a new image Play the audio code

Enter the code from the image

Wholesale Dealer Application

Thank you for your interest in the Patagonia Dealer program.

Applicant

Company / HQ

Address

Business Contacts

Manager

Owner

Accounts Payable

Details

Memberships / Attachments