Wild West Mercantile

Registration

Customer Information
* Is Required Information

First Name*

Last Name*

Company Only fill in Company if being shipped to a business.

Email*

Daytime Phone Number*

Fax

Billing Information
(Must Exactly Match Your Credit Card Billing Address)

Address*

Apt. / Suite

City*

State*

Zip Code

Country (US Only)

Shipping Information
(Leave Blank if Shipping to Billing Address.)

Address Book Title (i.e. Work)

First Name

Last Name

Company

Address

Apt. / Suite

City

State

Zip Code

Country (US Only)

Phone

Payment Information (SECURE!)

Payment information is not required for registration. However, you can not purchase from our site until you complete this information, which you can update at a later date.

Payment Method

Card Holder's Name

Card Number
[only digits]

Card Expiration Date /

Account Information

Desired Username*

Please use only letters and numbers no spaces for your Username.

Password*

Confirm Password

Remember My Password
E-mail me when you have special sales!

Your email address will be kept strictly confidential.

Please verify all your information is correct before clicking the Create Account button.