Submit Method Internet This form may be sent to sales@jenlis.com Fax/Mail This form may be faxed or mailed

	Wholesale Registration Form
	Please complete all required fields. Your email address is required for further contact Please hit the DONE button on the lower right when finished. Florida businesses: please fax a copy of your Tax ID to (954)956-1642

Contact Name (required)

Company Name (required)

Address 1 (required)

Address 2

City (required)

State (required)

Zip Code (required)

Phone (required)

Email (required)