Dealer Application | www.aquaessentials.com

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*
Applicant Information
Applicant Name*
Applicant Title*
Application Date*

Questions? Need more info?

204 Space Park S Drive
Nashville, TN 37211

Tel: 615-942-7867
Fax: 615-345-0500