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XMRE | Become a Dealer
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Company Name
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Primary Contact
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Email
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What products are you interested in?
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1300XT
Lite
Blue Line
GI Entree
Custom Pack
Please select all products of interest.
Web Site
Billing and Shipping Information
Address
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Street Address
Address Line 2
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Are BILL TO and SHIP TO the same address?:
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No
If No, attach list of Ship To addresses:
How long at current location?
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Company Information
Type of Business:
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Business License or SS#:
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Year Established:
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Is the business incorporated?
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If so, under laws of what state?:
Ownership (Names/Addresses/Contact/Telephone)
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If you are the owner and filling out this form, input "Owner". If not please include ownership information.
Accounts Payable Information
Accounts Payable Contact:
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First
Last
Accounts Payable Email:
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Accounts Payable Phone:
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I (we) certify that the above information is true and correct and that we can and will comply with your terms. If any legal or correction action is needed, I (we) agree to pay all applicable collection or legal fees.
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