please print and fill out the information required below. fax to 888-588-1033. you can also copy this to an email and email

Nomadic State of Mind-Dealer application

Business Name:

Street Address:

City: State: zip:

Legal owner:

Bill to: (if different from above)

Street address:

City: State: zip:

Phone # fax #

Website:

Email:

type of store:

Federal tax ID#

Reseller permit#

Date store started:

Please list all other selling locations: (if any) *

Why do you want to sell our products at your location?