Reseller Application – The Original Resinator

Business Name*
Name*
First Last
Phone
Intl. Phone
Email*
Intent*
- eCommerce
- Brick & Mortar Location
- Both
Website URL
Reseller Certificate
Accepted file types: jpg, png, pdf, Max. file size: 40 MB.
Federal Tax ID
State of Incorporation*
Shipping Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Billing Name
First Last
Billing Address (if different than shipping)
Same as Shipping

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Have you been working with a representative from our team? If so, who?
Messages
Any additional information that we may need about your company
Name
This field is for validation purposes and should be left unchanged.