Reseller Application

RESELLER APPLICATION FORM

Applicant

Name

Company

Company Name

DBA

Company Information

Billing Address

City

State

ZIP

Telephone #

Website URL

Billing and shipping addresses are the same

Owner Information

Name

Business Details

Year Business Established

Tax ID

State of Formation

Estimated monthly order value (in units)

Type of Business Entity

Resale Certificate (FL Only)

What is your company warranty for labor?

What is the range of your service area? (in miles)

Do you also sell online? Yes No

By checking this box, I certify that the above information is accurate and I agree to AIRLOCK’s reseller terms and policies.

Name

Date