Click, Drag, Hi-Lite , Copy & Paste the following form, then email to jstewart_01@msn.com 

Dealer Request Form  

Name of Company:_________________________________________ 

Sales Tax ID #:___________________________________________

Contact & Owner's Name:____________________________________

Bill To Address:____________________________________________

____________________________________________________________

____________________________________________________________

Ship to Address:___________________________________________

____________________________________________________________

____________________________________________________________

Business Phone:___________________________________________

Cell Phone:_________________________________________________

Fax:____________________________________________________

Email Address:_____________________________________________

Web Address: _____________________________________________

Brief Description of Services:_______________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

I, _(name)_______________________ , have read and do understand the NX advertising rules, and the information that I have stated and provided on this form is true to the best of my knowledge.