Distributors Registration – The Eternal Niche

Distributor Registration

Fields with an * are required

Distributor Legal Name*

Distributor Type of Business Entity*

State of Incorporation

Legal Address*

Legal Address 2

Legal Address 3

City*

State*

ZIP*

Ship to Address*

Ship to Address 2

Ship to Address 3

City*

State*

ZIP*

Phone Number*

Fax

Distributor Owner Contact*

Direct Phone Number*

Email Address*

Distributor Purchasing Contact*

Direct Phone Number*

Email Address*

Distributor Accounts Payable Contact*

Direct Phone Number*

Email Address*

Name of Person Filling out this form*

Title*