Retail Music Dealers Form

Please print out this form and mail it to us at the address below.

Dealer Name: _______________________

Purchasing Contact Name (if different from above): _____________________________

Store Name: ____________________________________

Address:_______________________________________

City, State, Zip: _________________________________________

Billing Address (if different from above): _________________________________

City, State, Zip: _____________________________

Phone: __(_____)______________________

Fax: __(_____)____________________

Email: ____________________________________

Web Address: ________________________________

Please list what the store sells: ___________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Please indicate if you are interested in hosting Manduca Music Publications Clinician workshops:

     ______ Yes

     ______ No

Please list three other publishers that you currently do business with. Include phone numbers or e-mail addresses if you have them:

_____________________________________________________

_____________________________________________________

_____________________________________________________

Mail to: Manduca Music Publications
   861 Washington Avenue
Portland, Maine 04103-2728