Dealer Questionnaire

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Type of Organization *

Please select one.

Company Name *

Please enter the entities legal name as registered. If Sole proprietor, enter the registered dba or fictitious name.

Name under which your store operates

For Corporations or LLC's. please enter the registered dba or fictitious name.

Position with Store *

What position do hold within the organization? Owner, President, Vice President, General Manager, etc

Name *

First

Last

Email *

The stores main email address where you wish to receive notifications.

Phone *

The store's main telephone number

Cell Number

Please provide a cell number if you wish to communicate by text/sms or if you will be calling from this number when contacting a representative.

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Website / URL *

Number of store locations

Selected Value: 1

Please slide to indicate the total number of stores you are selling JUKI products from.

What other brands do you sell

baby lock
Bernina
Brother
elna
Husqvarna Viking
Janome
Pfaff
Singer
APQS
Grace Frame- Q'nique
Handi Quilter
Innova

Please select all brands you are an authorized dealer for.

Do you sell online *

No
Yes - from our website only
Yes - our website and third party websites

Normal Business Hours *

Please list days and hours your store is open.

Other Services Your Store Offers

Sewing Classes (all types)
Repair (domestic machines)
Fabric sales
Long Arm Sales & Service
Customer Premise Machine Service

Do you have an Enewsletter? *

Would like other memebers of your staff to receive emails from the JUKI Sales team

Additional Store Contact

First

Last

This may be a manager or other person you wish to receive emails from our marketing and sales teams.

Additional Contact Position

What position do hold within the organization? Owner, President, Vice President, General Manager, etc

Additional Store Contact Email

By providing an email you are indicating your wish this contact to be included in all emails from the Marketing and Sales Teams.

Additional Contact 2

First

Last

This may be a manager or other person you wish to receive emails from our marketing and sales teams.

Position with Store 3

What position do hold within the organization? Owner, President, Vice President, General Manager, etc

Email 2

By providing an email you are indicating your wish this contact to be included in all emails from the Marketing and Sales Teams.

Address Store 2

Address Line 1

Address Line 2

City

State

Zip Code

Additional Store Entry

Address Store 3

Address Line 1

Address Line 2

City

State

Zip Code

Additional Store Entry

Address Store 4

Address Line 1

Address Line 2

City

State

Zip Code

Additional Store Entry

Address Store 5

Address Line 1

Address Line 2

City

State

Zip Code

Additional Store Entry

Address Store 6

Address Line 1

Address Line 2

City

State

Zip Code

Additional Store Entry

Address Store 7

Address Line 1

Address Line 2

City

State

Zip Code

Additional Store Entry

Address Store 8

Address Line 1

Address Line 2

City

State

Zip Code

Additional Store Entry

Address Store 9

Address Line 1

Address Line 2

City

State

Zip Code

Additional Store Entry

Address Store 10

Address Line 1

Address Line 2

City

State

Zip Code

Additional Store Entry

Address Store 11

Address Line 1

Address Line 2

City

State

Zip Code

Additional Store Entry

Address Store 12

Address Line 1

Address Line 2

City

State

Zip Code

Additional Store Entry

Address Store 13

Address Line 1

Address Line 2

City

State

Zip Code

Additional Store Entry

Address Store 14

Address Line 1

Address Line 2

City

State

Zip Code

Additional Store Entry

Address Store 15

Address Line 1

Address Line 2

City

State

Zip Code

Additional Store Entry

Shipping Account *

Please select the ground shipping carrier and enter the account number in the box below. If you select "Other", please indicate carrier the "Carrier" box below.

Shipping Carrier Account Number *

"Other" Selected - Please list carrier name

Additional Comments

Please enter any comments or additional names and emails you would like us to add to our email lists. This may include your service technicians. If noted as a technician, emails will be limited to service related notifications only.

Dropdown

Name

First

Last