Dealer Registration

Interested in becoming a Kelly’s Bass Worms dealer? Simply fill out the registration form below to submit your request! Have questions about becoming a dealer? Contact Christie Turnbow at (260) 484-5313 or

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Dealer Details

Store Address*

Credit References

Please list two tackle manufacturers or other wholesale vendors that can be used as credit references.

Dealer Indentification

Please upload a copy of your registered retail merchant certificate or state sales tax license. This document will have your tax ID and store name/address.
Max. file size: 10 MB.
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