Nitro Dealer Application

Phone *

Country

(###)

###

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Shipping Address

(if different than billing)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Type of Business *

Corporation

S-Corporation

Partnership

Sole Partnership

Non-Profit

Primary Contact Name *

First Name

Last Name

Primary Phone *

Country

(###)

###

####

Buyer Name

First Name

Last Name

Buyer Phone

Country

(###)

###

####

Accounting Name *

First Name

Last Name

Accounting Phone *

Country

(###)

###

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Reseller Type *

Roaster

Equipment Dealer

Distributor

International Distributer

Manufacturer

Other

Type of Channel *

Direct Sales

E-Commerce

Integrator