EpilaDerm Registration

Contact Information
Full Name*

First NameLast Name
E-mail*
Contact Phone*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please note; EpilaDerm is a professional product sold to professionals that are allowed to wax under the scope of their license. Thank you for your understanding.
Type of License*

AestheticsCosmetologyBarberWaxingOther
Licensing Information

This information is nessassary to keep EpilaDerm a professional product.
Name on License
License Number
State of License
Salon Information
If your company has multiple locations please provide info on the mail location only.
Salon Name
Salon Phone
Salon Website
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
General Comments
Should be Empty: