Dealer Form
Please print out this form and mail it to us at the address below.
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Dealer Name: _______________________
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Purchasing Contact Name (if different from above): _____________________________
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Store Name: ____________________________________
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Address:_______________________________________
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City, State, Zip: _________________________________________
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Billing Address (if different from above): _________________________________
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City, State, Zip: _____________________________
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Phone: __(_____)______________________
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Fax: __(_____)____________________
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Email: ____________________________________
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Web Address: ________________________________
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Please list what the store sells: ___________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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Please indicate if you are interested in hosting Manduca Music Publications Clinician workshops:
______ Yes
______ No
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Please list three other publishers that you currently do business with.
Include phone numbers or e-mail addresses if you have them:
_____________________________________________________
_____________________________________________________
_____________________________________________________
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Mail to: Manduca Music Publishing
861 Washington Avenue
Portland, Maine 04103-2728
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