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Dealer Application
Nexus 21 Dealer Application
Fields marked with an asterisk (*) are required
*Company Name:
Today's Date
*Contact Name:
Title:
*Email Address:
Website:
*Street Address:
*City:
*State:
Non-US
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*Zip Code:
*Phone:
Fax:
*Please select your type of business:
Custom Builder
Custom Builder
Interior Designer
Architect
Cabinet Maker
Architectural Woodworker
Boat Builder
RV / Coach Builder
Others (please specify)
Year Your Business Was Founded:
Number of Employees:
Do you have a
Retail Store
Show Room
Design Center
Other
*Do you have an immediate need for a lift system?
Yes
No
*Do you currently sell any type of TV Lifts?
Yes
No
If yes, do you currently have a floor model of some lift system on display?
Yes
No
Are you interested in learning about our Preferred Dealer Program which gives you an extra discount on all lift purchases in return for showing a Nexus 21 Lift in your showroom?
Yes
No, Thanks
Do you include TV Lifts in any of your advertising or marketing?
Yes
No
If yes, what type of ads? (printed ads, internet marketing, trade shows, etc.)
Comments: