DEALERS

DEALER APPLICATION FORM

To anyone interested in being a LUMENEZ product dealer, please click here to review our dealer policy before filling out the electronic form below. A LUMENEZ representative will contact you after the form has been processed. Please note, all fields marked by an asterisk (*) are required to submit the form. Thank you for your interest in our products, and we look forward to working with you!

Name *

Company Name

Company Position i.e. owner, manager, etc.

Address *

City *

State *

Zip Code *

Phone Number *

Fax Number

Email Address *

Website

Ebay ID

Tax ID Number

How did you hear about us?

Where do you plan to sell our product? i.e. internet, retail store, etc.

Do you sell HID related products?

Have you ever tried our products?

Which of our products are you interested in carrying? (Check all that apply)

HID Kits D1R/D1S Bulbs D2R/D2S Bulbs