Advaning Authorized Dealer Form

Authorized Dealer Application Form

* indicates required fields

First Name*

Company Name

Work Phone Number*

Fax Number

Accounting Phone

Address

State

Country

Last Name*

Job Title

Cell Phone Number

Email*

Accounting Contact Name

Accounting Email

City

Zip Code

Federal ID Number

Dun and Bradstreet Number

Sales Tax

Taxable Exempt

Target market

Residential Commercial Other (Enter details on the right)

Other

Website

Do you currently sell online?

Yes No

If yes, please list website

Tell Us about your company

Please attach tax exemption document

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