STRIPER SPOONS DEALER APPLICATION   Please fill in the following information.  We will review your application and contact you immediately upon approval.  For quickest response please us at 866-393-0700 (toll free), Monday through Friday from 9:00am to 5pm (EST) after completing the application.     Company name (required) Contact first name Last name  (required) Email address Mailing address (required)   City/State/Zip Select NY AL AK AS AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MN MT NE NV NH NJ NM NC MD MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY     (required) Country United States Canada Albania American Samoa Andorra Angola Anguilla Antigua Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Benin Bermuda Belize Bolivia Bosnia-Herzegovina Botswana Brazil British Virgin Is. Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Chad Cayman Islands Chile China Colombia Congo Congo, Democratic Republic of Cook Islands Croatia Costa Rica Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malaysia Malawi Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mexico Micronesia Moldova Monaco Montserrat Morocco Mozambique Namibia Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Paraguay Palau Palestine Autonomous Panama Papua New Guinea Peru Philippines Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saipan Saudi Arabia Senegal Seychelles Singapore Slovak Republic Slovenia South Africa South Korea Spain Sri Lanka St Kitts/Nevis St Lucia St Vincent Suriname Swaziland Sweden Switzerland Syria Taiwan Tanzania Thailand Togo Trinidad/Tobago Tunisia Turkey Turkmenistan Turks & Caicos U.A.E. U.S. Virgin Islands Uganda Ukraine United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis & Futuna Yemen Yugoslavia Zambia Zimbabwe Phone/ext (required) Website Tax certificate#       The following information is used for secure online ordering, please record your user name and password in a safe place. User ID (minimum 8 characters) Password (minimum 8 characters)
	Secret Spoons c/o Captain Jackies 55 Highland Avenue Port Washington, NY 11050
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