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LedXtreme Dealer Form
LedXtreme manufactures the finest L.E.D. products for personal and business use. LedXtreme is dedicated to the success of those retailers by producing the highest quality flashlights. Please complete and submit the form below and a LedXtreme representative will contact you shortly.

DEALER INFORMATION
REFERENCE #


COMPANY NAME


SHIPPING ADDRESS



CITY
PROV / STATE

COUNTRY
POSTAL / ZIP CODE


EMAIL ADDRESS

How did you get to our Web Site today?


Other

CONTACT NAME



PHONE NUMBER
  ext.
FAX NUMBER
  



Type of Sales
Store(s)   Number of Stores
Internet

Your Website


YEARS IN BUSINESS 

LIST YOUR PRIMARY CUSTOMER TYPES / MARKET(S)


PRODUCTS AND QUANTITIES YOU ARE INTERESTED IN

Additional Information:

"The Brightest and Whitest High Quality L.E.D. Products"