Dealers Registration

Register to become a Carrotstix Dealer

BILL TO:

Legal Name:*
Trade Name:*
Billing Address:*
Phone:*
-
Fax:
-
E-mail:*

SHIP TO:

Company Name:*
Shipping Address:*
Phone*
-
Tax Exemption #:
website:
Number of Locations:
Business Established Date:

ABOUT YOU:

You are a:
What best describes your business?
(Please specify):

KEY CONTACTS:

Name:
Password:
Do you use a purchase order system?
Other Purchaser:
AP Name:

GENERAL AGREEMENT:

By agreeing,I / We certify all information is correct and agree to notify Carrot Stix™ immediately in the event of any change to the above: