New Dealer Inquiry
Please fax the following information for review to become an EILUX product reseller.
By Submitting This Form You Agree To Abide By The MAP Policy Set Forth By EILUX International.

MAP POLICY
Last Name:   ___________________________________                                                                                
                                                                
Title:   ___________________________________                                                                                
                                                                
Company Name:   _________________________                                                                                
                                                                
Tax ID Number:   _________________________                                                                                
                                                                
Address:   ________________________________________                                                                                
  ________________________________________                                                                                
  ________________________________________                                                                                
  ________________________________________                                                                
                                                
Telephone:   ____________________                                            
                                                
Fax:   ____________________                                                                
                                                
Website Address:   ___________________________________                                                                
                                                
Email:   ________________________________________                                                                
                                                
Briefly Describe Your Company:   ______________________________________________                                                                
                                                
                                                
                                                
                                                
Comments / Questions:   ______________________________________________________                                                              
                                                 
                                                                
                                                                
                                                          
Fax  To:   330-722-7152