Dealer Application Contact Information Please provide the primary contact's informaiton below. Additional contacts may be added once the account has been approved. Company* Doing Business As Name (if needed) Primary Contact: First Name* Primary Contact: Last Name* Primary Contact: Title Primary Contact: Email* Primary Contact: Phone* Billing Address Billing Address* Billing City* Billing State Billing Zip Code Billing Country Shipping Address Shipping Same as Billing Shipping Address Shipping City Shipping State Shipping Zip Code Shipping Country Online Access Sign-up for Online Ordering Tax & Insurance Files Please provide the following required files, if applicable to your business. Attach Sales Tax Exemption / Resale Certificate Max 20 MB Attach Proof of Insurance Max 20 MB Attach IRS Form W-9 - Identification of Taxpayer Max 20 MB Billing Information Method of Payment* -None- Prepayment via Credit Card (MC, VISA, AMEX) Check ACH Flooring Line of Credit (Application Required) Applicant Information Applicant Name* Applicant Title* Application Date* Questions? Need more info? Contact us Our Address 223 Space Park S Drive Nashville, TN 37211 General inquiry info@youraquaessentials.com orders@youraquaessentials.com Phone number Tel: 615-942-7867 Fax: 615-345-0500