Shadow Effect

Please use this form and fill out as much information as you could to better assist us in your enrollment. We will respond as quickly as possible. All fields marked * are required. Please ensure phone and email details are completed so we can contact you if needed. You could also contact us from 8:00am until 5:00pm EST Monday to Friday at 800.867.2216


Dealer Enrollment Form
Dealer Name*
 
 

DBA Name
 


Authorized Contact Name*
 
 

Address*
 
 

City*
 
 

State*
 
 

Zip*
 
 

Phone*
 
 
Fax
 
Email*
 
   
Average Monthly Sales
 
Total Number of Locations
 
Web Sales
 


States/Provinces Operating
 
If Yes, What Member Buying Group
or Trade Association are you with
 
Select Programs
 
Appliances
Computers
Electronics
Furniture-Comprehensive
Furniture-Limited
Furniture-Aftermarket
Jewelry
Musical Instruments
Outdoor Power Equipment/Tools
Pool Equipment
Sporting Goods/Fitness
Other Program
 
Trade Reference
 




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