Wholesaler Information

To sign up to be a Rembatt Dealer, fill out the form below for review:

Company name:

Main Contact name:

Main Contact email:

Main Contact phone number:

Billing Address:

Billing City:

Billing State:

Billing Zip:

Billing Email Address:

Billing Phone Number:

Physical Address:

Physical City:

Physical State:

Physical Zip:

Physical Email Address:

Physical Phone Number:

Ship-To Address:

Ship-To City:

Ship-To State:

Ship-To Zip:

Ship-To Email Address:

Ship-To Phone Number:

Accounts Payable Address:

Accounts Payable City:

Accounts Payable State:

Accounts Payable Zip:

Accounts Payable Email Address:

Accounts Payable Phone Number:

Expected quantity ordered each month:

Other Arrangement: