Company Name: *

First Name: *

Title:

Address:

City:

State:

Phone: *

Fax:

Would you like to receive emails with specials and promotions?
YesNo

Please classify your business & indicate the percentage (%) of business it represents for you:
Home based business%
Commercial storefront location%
Commercial business (no storefront)%

If Other (please explain):

Do you have any dedicated sales people?
YesNo
If Yes, how many?

Please indicate your companies sales volume in dollars for 2009:

Is your company a member of any buying group?
YesNo
If Yes, please provide your Membership #:

What companies do you currently have distributor agreements with?
Payment optionsCredit CardCOD

I would like to apply for credit terms:
YesNo

How did you hear about EasyLift™?
Existing customer referralWeb searchPrint/magazine adCustomer requested your product
If Other (please explain):

Please provide a Federal Tax ID or State Resale Certificate #

Email for Invoices:

Email for Order Confirmations:

Comments / Questions: