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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:

*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.)

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