HyaFlex Dealer Application

HyaFlex™ Dealer Application
Thank you for your interest.
If you would like to become a HyaFlex™ dealer please fill out this form and we will contact you promptly.
Please provide the following contact information. Bold items are required.


How did you hear about us?
Contact Name
Title
Company
How many stores?
Accts. Payable Contact (if different)
Shipping Address
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Billing Address (if different than shipping)
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Phone
FAX
E-mail
URL
Do you use P.O. Numbers?	YesNo
Federal Tax ID#
Trade References
1.Reference Name
Reference Phone
2.Reference Name
Reference Phone
3.Reference Name
Reference Phone
Bank References
Bank
Contact
Phone
Other Comments
Any Additional Comments or Questions?