Company Name *

First Name *

Last Name *

Phone Number *

Fax Number *

Email *

How Long at Present Address? *

Year Established? *

Address *

Same as Bill-To Address
Same as Ship-To Address
Other

City *

State *

Zip or Postal Code *

Country *

Website *

DBA *

Tax ID *

DUNS *

Number of Employees *

Annual Revenue *

Industry/Business Type *

Business Organization *

Proprietorship
Partnership
Corporation
Other

State of Incorporation (if applicable) *

Company Principals (names & positions) *

AP Manager *

AP Email *

Bank Name *

Bank Acct # *

Bank Address *

Bank Contact *

Contact Email *

Bank Telephone *

Bank Fax *

Name of Person Who Authorizes Release of Bank Info *

Are you a reseller? *

Yes
No

Reference One

Company Name

Company Address/City/State/ZIP/Country

Contact Name

Contact Phone

Contact Email

Reference Two

Company Name

Company Address/City/State/ZIP/Country

Contact Name

Contact Phone

Contact Email

Reference Three

Company Name

Company Address/City/State/ZIP/Country

Contact Name

Contact Phone

Contact Email

Upload files (Reseller ......) *

Drag and Drop files here

File(s) size limit is 20MB.

temp-for-101952-file2-1_

*

Approval of wholesale accounts is at the sole discretion of Bulbtronics. You, as a wholesale customer (“I” or the “Customer”), agree to the following terms and conditions (“Terms”):

1. Upon being granted the rights of a wholesale customer, the Customer agrees to the following:

Only to list, sell, or offer to sell online through the website listed above, and not to list, sell, or offer to sell online through any other website, including, without limitation, Amazon.com or ebay.com, or Walmart.com:

Not to list, sell, or offer to sell online, any Bulbtronics product at a price lower than our MSRP; and

Not to list, sell, or offer to sell products without including the complete product descriptions, suggested usages, contradictions and warnings.

I agree not to alter, cover up, remove or change in any way Bulbtronics’s labeling, informational, and/or promotional material or to reprocess, reverse engineer, re-label or repackage any Bulbtronics product.

2. Bulbtronics may suspend or terminate the Customer’s wholesale account or otherwise cancel any Customer order, or any part thereof at any time and for no reasons or for any reason, including, but not limited to, the Customer’s violation of any of these Terms.

3. If any complaints or adverse reactions are reported from consumers, I agree to notify Bulbtronics immediately and will assist in gathering accurate information when possible to aid the further investigation.

By checking the box above, I agree to be bound by these Terms.

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LIGHT SOURCE QC1.59M QC1.59M

LIGHT SOURCE UPB