Notice: JavaScript is required for this content. FORM Fields marked with an * are required General Details General Details Prefix * First Name * Last Name * Your Role * Business Owner Business Partner Assistant Other Shop Name * Address Line1 * Address Line2 * City * Postal Code / Zip Code * Country - Select Country - Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia And Herzegowina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic Of The Cook Islands Costa Rica Cote D'Ivoire Croatia (Local Name: Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard And Mc Donald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic Of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic Of Korea, Republic Of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia, Former Yugoslav Republic Of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Of Moldova, Republic Of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts And Nevis Saint Lucia Saint Vincent And The Grenadines Samoa San Marino Sao Tome And Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia, South Sandwich Islands Spain Sri Lanka St. Helena St. Pierre And Miquelon Sudan Suriname Svalbard And Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic Of Thailand Timor-Leste (East Timor) Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis And Futuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe Business Telephone Number * Mobile Number * Website Address * Email * Do you have an online shop on your website? * Yes No Social Media Social Media Facebook * Instagram * Twitter * Other * Other * Other * Divider Do you own or lease your shop? * Own Lease/Rent Other How long have you been in business at these premises? * What size is your shop? * Do you have more than one shop? * Yes No If yes, how many? 1 2 3 4 5+ - What are your opening hours? Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Sunday: What size is your shop? * Divider Upload 1 or more photos of your shop exterior and frontage * Select Files Upload 1 or more photos of your shop interior. * Select Files Upload 1 or more examples of painted furniture for sale in your shop. * Select Files Name * Business Name * Email * Phone Number * Please add any details you feel necessary for your application. * How did you find out about Chalk Paint® and Annie Sloan? * Online Via an existing Stockist Word of mouth Social Media Print Media Through another brand Other
