WICCAWORKS PRODUCTS http://www.wiccaworks.com Store Info and Tax Number Form Effective April, 2004 Required for Wholesale Access DATE: -------------------------------------------------------------------------------- STORE Name: -------------------------------------------------------------------------------- CONTACT Name: (Name on driver's license) -------------------------------------------------------------------------------- State Tax #: -------------------------------------------------------------------------------- Address: -------------------------------------------------------------------------------- Address: -------------------------------------------------------------------------------- City: -------------------------------------------------------------------------------- State & Zip: -------------------------------------------------------------------------------- Phones: -------------------------------------------------------------------------------- Fax: -------------------------------------------------------------------------------- Email: (Also for invitation to WiccaWorks wholesale Yahoo group) -------------------------------------------------------------------------------- Use your mouse to copy the lines above and paste them into an email message, then send the message to: wiccaworks@yahoo.com or print, complete, and mail this form to: WICCAWORKS 4645 Commodore Ave. Spring Hill, FL 34606 Voice Phone: 1-352-688-1469