PIRIT Heated Hose : The Only Cold Weather Heated Hose

WHOLESALE APPLICATION

*First Name:		*Last Name:

* Company:

*Address 1:

Address 2:

*City:

*State/Province/Region :		*Zip/Postal Code :

*Country:

*Daytime Phone:		Evening Phone :

Fax:		*Tax ID/SSN:

* Website URL:

*Email:

*Password:

*Confirm Password :

DESIRED PRICING LEVEL

Wholesale

Please describe your business, where our products will be sold, and any other pertinent information to your application.

CERTIFICATE OF RESALE

Please upload your electronic certificate of resale using the field above.