Distributor Request and Information Form

 

Enter your comments in the space provided below.
Why do you want to become a distributor for us and
do you have a game plan for being a successful distributor?

 >>>Please fill out your information, lines in red are required:

Name:
Company:
Address:
City:
State:
Zip:
E-mail:
Tel:
FAX:
Payment Preference, please check one or both:
  PayPal>>>> Visa/MC/Discover Card to be kept of file

Orders can only be e-mailed in or faxed in to us.
If you prefer, you can either call me toll free or e-mail me your credit card 
information just prior to your initial order.
 

Please use our e-mail address:
george@hm-e.net
when paying by PayPal

Credit Card Information
Card Type
Full Name on Credit Card
Card Number


format: 1234-5678-9012-3456
Expiry (mm/yyyy)   

VisaMastercard

 >>>Toll Free (800) 443-2498 
 >>>FAX (413) 828-5846
 >>>george@hm-e.net

Horizon Micro-Environments, LLC
Copyright © 1999 [Horizon Micro-Environments, LLC]. All rights reserved.
Revised: July 06, 2007 .

 

>>>