Rollies.com - Create Customer Account


Shipping Terms	Wholesale	HELP	International Orders	Order Status

You must be at least 18 years of age to purchase from this site

Create Customer Account:

Please fill out the form below to create a customer account. * = Required Note: This is only your shipping and contact info. ALL ONLINE TRANSACTIONS WILL BE MADE OVER SECURE SERVER
* First Name:		ex: Bob
* Last Name:		ex: Smith
Company:		ex: Whatever inc.
* Address 1:		ex: 123 Tree St.
Address 2:		ex: Apt. 2
* City:		ex: Vancouver
* State:		ex: BC
* Country:		ex: Canada
* Zip / Postal Code:		ex: 90210
* Phone Number:		ex: 555-123-1234
Cell Phone Number:		ex: 555-123-1234
Fax Number:		ex: 555-123-1234
*Date Of Birth:	Year: Month: Day:	Age Must Be >= 18
* Account Email:		ex: me@you.com - This is the email you use to login to account and is where all our order status emails are sent
* Confirm Account Email:		Enter same email address as above to confirm correct address
* Account Password :		ex: 123ME45 Use this to login to your account,
* Confirm Account Password :		ex: 123ME45 Use this to login to your account,