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Saunagen™ Authorized Dealer  Request Form

  Company Information
       
  * Company Name:       DBA:  
  * Shipping Address:    
  * City:       * State:    * Zip:  
 
 
  Billing Address:    
  City:       State:     Zip:  
 
 
  * Phone:        Fax:      * E-Mail:  
  Type of Business:        
  * FED Tax ID #:      * Local Business Permit #:  
 
Do you have a Retail Store Front?     No. of Employees: 
 
 
Web Site:
 
 
* How long have you been in business?   Years Months
 
 
Name and Address of Retail Store:
  
 
* What items do you currently sell?
  
       
  Contact Person Information
       
  * Contact Name:       Social Security #:  
  Home Address:    
  City:       State:     Zip:  
 
Billing Contact Name:      Phone:
 
 
 
    (* is required fields)  
       
 


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Last Modified:  08/20/04

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