Retail Store Owners

The fields marked with * are mandatory

To qualify for our Reseller Program you must have an established retail store and a Sales Tax ID Number. If you meet these criteria and are interested in becoming a FireBUGS Retailer, please fill out and submit the following form and a TimbukTEK representative will contact you soon.

Company Name:

Contact Name:

Street Address:

PO Box, Route #, etc:

City:

State/Province:

Country:

Zip / Postal Code:

Phone (with area code):

Mobile Phone (with area code):

Email Address:

Web Site Address:

Merchant Type:

Sales Tax ID Number:

Number of Locations:

Comments:

Type the characters you see in the picture below.