General Information

Company Name *

Street Address *

Apartment, suite, etc (optional)

City *

State/Province *

Postal Code *

Country *

Business Main Phone *

Registration # / EIN (Optional)

Primary Contact

Our main point person for communication.

First Name *

Last Name *

Position or Title *

Primary Email *

Primary Phone *

Contact: Purchasing

The person responsible for issuing and sending purchase orders.

Same as Primary

First Name *

Last Name *

Position or Title *

Purchasing Email *

Purchasing Phone *

Contact: Accounts Payable

Facilitates timely payment of invoices if payment terms are granted.

Same as Primary

First Name *

Last Name *

Position or Title *

AP Email *

AP Phone *

Contact: Product Development

Incorporating our hardware may require customization. Collaboration with a qualified individual is critical.

Same as Primary or Not Applicable

First Name *

Last Name *

Title *

Product Dev Email *

Product Dev Phone *

Purchasing & Ordering Preferences

What email should we use to set up your account? This will be your login for placing and tracking orders.

Account Email Address *

Select the number of units you expect to order each month.

Estimated Monthly Units *

Upload Any Relevant Documents (Resale Certificate, Business License, etc.)

Choose file or drag here

Supported format: JPG, JPEG, PNG, GIF, SVG.

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Optional

I certify that the above information is accurate and that I am authorized to apply for reseller pricing on behalf of this business. *

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General Information

Primary Contact

Contact: Purchasing

Contact: Accounts Payable

Contact: Product Development

Business Survey

Purchasing & Ordering Preferences

Currency

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