Authorized Dealer Program Registration Form

Authorized Dealers for TruXedo, Inc. are defined as accessory retailers who sell TruXedo products and have our display unit or stock TruXedo products.

* Required Fields

Physical Address
Dealer Name:		*Contact Name:
*Address:		Address 2:
*City:		*State:          AL AB AK AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NH NJ NM NS NV NY OH ON OK OR PA PQ QC RI SC SD SK TN TX UT VA VT WA WI WV WY
Country:	USA CANADA	*Zip:
*Phone:	(ex. 123-456-7890)        Fax:
Email:
Website:
Mailing Address
If mailing address is different than above

Company Name:
Address:		Address 2:	City:	*State    Select AL AB AK AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NH NJ NM NS NV NY OH ON OK OR PA PQ QC RI SC SD SK TN TX UT VA VT WA WI WV WY
Country:	Select USA CANADA	Zip:

Do you currently have a display unit? Yes No

If yes, what display unit(s) do you currently have? Lo Pro QT Original TruXedo TruXport Deuce

If yes, Who did you receive the Display Unit from?

If no, would you like us to send you a Display Unit? Yes No

Where did you first hear of TruXedo Products?

How long have you sold TruXedo Accessories?

Do you stock TruXedo? Yes No

Do you sell TruXedo online? Yes No

Do you carry any other tonneau covers? Yes No

If so, what brands?

Would you like to receive our email newsletters? Yes No

Would you like to receive our fax announcements? Yes No

Would you like to order your Display Units now? Yes No