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            First Name *
            
        

        
            Last Name *
            
        
    

    
        Shop Name *
        
    

    
        Shop URL *
        
        
        https://ruangjualan.com/vendor/
    

    



    Address

    
                    
                Street                                              *
                                    
                
            
                        
                Street 2                                    
                
            
                        
                                    
                        City                                                             *
                                                    
                        
                    
                                        
                        Post/ZIP Code                                                             *
                                                    
                        
                    
                                
            
                        
                Country                                              *
                                    
                
            
                        
                State                                     
                                    
                                
        
            

                    
                Company Name
                
            
        
                    
                Company ID/EUID Number
                
            
        
                    
                VAT / TAX ID
                
            
        
                    
                Name of Bank
                
            
                
    
        Phone Number*
        
    

            
            
            
                I have read and agree to the Terms & Conditions.            
        
        




    
        
        I am a customer    
    

    
        
        I am a vendor
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