Dealer Application - Halo Lockers

Dealer Application

Company Name *

Phone # *

Fax #

Email Address *

Website URL

Contact Name *

Contact Person position *

Physical Address *

City *

State/Province *

ZIP / Postal Code *

Country

I will use this address as my Billing Address *YesNo

Billing Address *

City *

State/Province *

ZIP / Postal Code *

Country

I will use this address as my default Shipping Address *YesNo

Shipping Address *

City *

State/Province *

ZIP / Postal Code *

Country

Type of Busines

Years in Business

Do you promote and sell products online? *

Does the company install this product? *

How many lockers do you sell anually? *

Employer Identification Number *

Sales Tax ID

Upload Sales Tax Certificate

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Please upload a copy of your Sales Tax Certificate