Nexus 21 Dealer Application


Fields marked with an asterisk (*) are required

*Company Name:
*Contact Name:
*Email Address:
Today's Date
Title:
Website:
*Street Address:
*City:
*Phone
*State:
*Zip Code
Fax:

*Please select your type of business:


Year Your Business Was Founded:
Number of Employees:
*Do you have a

*Do you have an immediate need for a lift system?
*Do you currently sell any type of TV Lifts?         If yes, what type:    
If yes, do you currently have a floor model of some lift system on display?

Do you include TV Lifts in any of your advertising or marketing?
If yes, what type of ads? (printed ads, internet marketing,
trade shows, etc.)

What else would you like to tell us about you?

    "We send product and pricing updates to our dealers by email. Please check the box to grant us permission to email you. We will also share information with you once in a while that will be helpful to you as a TV Lift dealer, but we will not abuse the privilege, and we will never share your email address with anyone else."