Killn Stix Dealer Application

Killnstix Dealer Application
Dealer Information
Name*

First NameLast Name
Company Name*
Enter your Company's name.
Email*
example@example.com
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Phone*

Area CodePhone Number
Cell Phone

Area CodePhone Number
Tax ID / Business Number*
Enter Tax ID / Business Number
Date of Incorporation*

MonthDayYear
Date
Billing Information

(if different from Dealer Information)
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
TRADE REFERENCES

(Minimum 2 references. Enter any additional trade references in the message box below.)
Reference 1
Name*

First NameLast Name
Business Name*
Business Phone

Area CodePhone Number
Reference 2
Name*

First NameLast Name
Business Name*
Business Phone

Area CodePhone Number
Additional Info

If any additional information you'd like to send, add it below.
Enter any relevant additional info not covered by this form.
Declaration*

I declare that the above application is correct and agree to the Terms and Conditions as outlined below.
I/We the undersigned declare that the above application is true and correct and agree to the Terms and Conditions as outlined in the current dealer price list. I/We accept the Trading Terms being strictly COD/CC unless otherwise agreed with an Authorized Officer of Five In The Eye Productions Inc. I/We are personally guarantee to pay in full for any goods which have been received by the above mentioned and are held personally liable for any outstanding debts at any stage.
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Killnstix Dealer Application

Dealer Information

Billing Information

TRADE REFERENCES

Reference 1

Reference 2

Additional Info