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:: Distributor Application ::    

:: Distributor Application ::

UV Connections - Leaders In Ultra Violet LED Technology

Please provide information about your company
 (All Fields Are Required Except Shipping Address)

Business Information:
Owner's Name:
Business Type:
(choose one) 		Sole Proprietor Corporation Limited Liability Corporation
Company Name: Years in Business:
Federal Tax ID #: License #:
Wholesale/Retail  
Primary Contact Name and Address:
Primary Contact Name: Email Address:
Street: City:
State: Zip Code:
Phone: Fax:
Shipping Address: (If Different From Primary Contact Address)
Street: City:
State: Zip Code:
Please Supply Three Business References:
Company: Contact Name: Phone:
1:
2:
3:
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