Mia Mélange Wholesale Application Form
Thank you for applying to be one of our valued stockists.

After you fill out this form, we will notify you as soonest to let you know if your application was successful or not. We appreciate your patience.

If you have any questions in the meantime, please feel free to contact us at info@miamelange.com

First Name
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Last Name
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Registered Business Name
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Trading Name
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Vat Number
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Contact Number
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Alternative Number
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Business Address
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Shipping Address
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Email
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Website
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Facebook
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Instagram
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How did you first learn about us?
How many years has your business been running?
What is the nature of your business?
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Why do you think our products fit your type of business?
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How do we fit in your business plan?
Comments & Suggestions
Please tell us more! We are always striving to improve, feel free to comment or give us any suggestions you have.
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