Valken Dealer Application Short Form

DEALER APPLICATION SUBMISSION FORM
Become a Valken Dealer

Thank you for your interest in carrying Valken products. We need to be familiar with each Customer that wishes to carry our products, so please complete this application.

Requirements:
- Applicant must own or in the process of owning a store or field
- A picture of the store or field (or future site) must be supplied before account is opened.
- All new domestic accounts are subject to a $750.00 opening order
- Overseas accounts are subject to a $2500.00 opening order.
Company Name - Customer*
Trading As*
Principal Business Address*
City*
State*
Zip Code*
Country Code*
Phone Number*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
E-mail*
Website / URL*
---------------------------------------------------------------------
All of the information provided is accurate and complete, and you authorize us to verify the accuracy of all information contained in this application.

The relationship and transactions between Customer and Valken shall be governed exclusively by the

Wholesale Customer Agreement which may be retrieved, printed and reviewed on http://www.valken.com/terms-and-conditions

Please Enter The Characters Below To Verify Your Submission:
Enter the message as it's shown*
Should be Empty: