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Reseller application

Account Application Instructions:

1, Please complete as much info as you can below

2, Pleas fax this page with a copy of your Business License/Resale Permit and owner's Driver's License.

Account FAX Application Requirement

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1305 Lakes ParkWay Suite # 107 Lawrenceville GA 30043 * Ph: 678-407-4983 * 678-407-2062 * Fax: 678-407-0262

www.iPremiertek.com  sales@ipremiertek.com

Legal Business Name -
President/Owner -
Doing Business As -
Shipping/Billing Address -
Business Phone Number -
Business Fax Number -
E-mail Address -
Business Website Address -
Authorized Purchaser -
Date Business was founded -
Length of time at this address -
Items You are interested -
Quantities per item -
Items You are interested -
Quantities per item -
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