Become a Retailer

Legal Name:

Trade Name:

Website Address:

Year Business Started:

Billing Address Name:

Address 1:

Address 2:

Address 3:

City:

State:

Zip:

Country:

Shipping Address Name:

Address 1:

Address 2:

Address 3:

City:

State:

Zip:

Country:

Resale License or VAT #

Buyer Name:

Buyer Telephone:

Buyer Fax:

Buyer Email:

Sales Representative:

Accounting Contact Name:

Accounting Contact Telephone:

Accounting Contact Fax:

Accounting Contact Email:

Payment Terms:

Payment Method (wire, check):

Freight Billing (prepay, prepay & add, collect):

Preferred Carrier:

Account Number:

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Address

12317 Technology Blvd Suite 300
Austin, TX 78727
(800) 615 – 1BRA

183 Madison & 34th Street
Suite 618, 6th floor
New York, NY 10016

[email protected]