516-901-0466
Wholesaler's Password Request Form
Wholesaler's, for password access to Lobster-N-Crab's up-to-date wholesale pricing, request your Username and Password today.
(
RED
=
NOT Required
but helpful)
To fax us this information,
download the pdf version
,
fill out, print and fax to
1-516-901-0466
Contact Information
Company Name:
Contact Name:
Email:
Create Your Username & Password
Username:
(4 char min, 10 char max)
Password:
(4 char min, 10 char max)
Enter Same Password:
(4 char min, 10 char max)
Billing Address Information
Address:
Address (line 2):
City / State / Zip:
,
Country:
Shipping Address Information
Check if same as Billing Address Info
Address:
Address (line 2):
City / State / Zip:
,
Country:
Additional Information
Phone:
Fax:
Cell Phone:
2nd Fax:
Website:
Wholesale Type:
National Seafood Distributors
Regional Seafood Distributors
Food Service Distributors
Chain Restaurant
Supermarket Chain
Broker
Retail
Other (please specify)
Expected Monthly Volume:
Preferred Method of Payment
Visa
Mastercard
Other (please specify)
Receiving Instructions:
516-901-0466 / Fax: 516-977-0693
