Daphyls_ Reseller Application

Thanks for registering to be one of our retail partners. Please fill in the information below which is confidential and only used to verify your reseller status.

Company's Name*

Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Tax Id / Resale #*

Primary Company Contact*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Website Address

What Kind of Business Are You*

How Do you Currently Advertise Your Product Lines*

Social Media Accounts