Application

Contacting us for :(Required)

Name of Person Completing Application(Required)

First Last

Email(Required)

Phone(Required)

How did you find us?(Required)

GENERAL BUSINESS INFORMATION

Legal Name of Company(Required)

DBA (Doing Business As)

Billing/Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Fax

Website

Years in Business(Required)

Business Ownership(Required)

Corporation

Proprietorship

Partnership

Annual Sales Volume

Estimated Monthly Purchases

Description of Business(Required)

SALES TAX EXEMPTION INFORMATION

PLEASE UPLOAD A DIGITAL COPY OF YOUR RESALE CERTIFICATE BELOW

Sales Tax Resale Number(Required)

Resale Certificate(Required)

Accepted file types: jpg, png, pdf, Max. file size: 50 MB.

BUSINESS PRINCIPALS INFORMATION

Name of Principal #1(Required)

First Last

Principal's Title(Required)

Principal's Phone(Required)

Principal's Email(Required)

Partner Portal Access

Yes

No

Name of Principal #2

First Last

Principal #2 Title

Principal #2 Phone

Principal #2 Email

Partner Portal Access

Yes

No

PURCHASING INFORMATION

Person Who Will Place Orders(Required)

First Last

Phone(Required)

Email(Required)

Partner Portal Access

Yes

No

Send Shipping & Tracking to:(Required)

First Last

Phone(Required)

Email(Required)

Partner Portal Access

Yes

No

ACCOUNTS PAYABLE INFORMATION

Name of Controller(Required)

First Last

Controller's Phone(Required)

Controller's Email(Required)

Partner Portal Access

Yes

No

Accounts Payable Contact(Required)

First Last

AP Phone(Required)

AP Email(Required)

Partner Portal Access

Yes

No

Preferred Delivery Address(Required)

AUTHORIZED RESELLER SIGNATURE

Digital Signature Waiver(Required)

I Agree

I Do Not Agree

As duly authorized signer for my company, I affirm that all of the information submitted in this form is accurate.

Signer Name(Required)

First Last

Title(Required)

Signature(Required)

Date(Required)

Phone

This field is for validation purposes and should be left unchanged.