Dealer Registration – Kelly's Bass Worms Dealer Portal

Complete the following form to register for your Kelly’s Bass Worms online dealer account. We will review your application once submitted. If approved, you will receive an activation email containing your account activation and login details.

Dealer Details

First Name(Required)

Last Name(Required)

Phone Number(Required)

Email Address(Required)

Store Name(Required)

Store Address(Required)

City(Required)

State(Required)

Zip Code(Required)

Are UPC Codes required on the products you will be ordering?(Required)

Credit References

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

Name of Manufacturer/Vendor #1(Required)

Phone Number(Required)

Email Address(Required)

Name of Manufacturer/Vendor #2(Required)

Phone Number(Required)

Email Address(Required)

Dealer Identification

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.

Retail Merchant Certificate(Required)

Max. file size: 10 MB.

Account Details

Please choose a secure password to use when logging into your new dealer account.

Password(Required)

Enter Password Confirm Password

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