Candela

• Company Name *
• Parent Company
  Only if applicable
• Attn
  Name to send mail attention to
• Street Address 1 *
• Street Address 2
• City *
• State *
  XX
• Zip *
  #####-####
• Phone *
  ###
  ###
  ####
• Fax
  ###
  ###
  ####
• Billing Email Address *
  Preferred email address for invoices (email@example.com)

• Contact Name
  First
  Last
• Email Address
  email@example.com
• Phone
  ###
  ###
  ####
  Ext
• Fax
  ###
  ###
  ####

• Owner Name *
  First
  Last
• Position *
• Phone *
  ###
  ###
  ####
  Ext
• Email Address
  email@example.com
• Business Entity *
  Proprietorship Partnership Limited Partnership Corporation
• If Corporation, list State and Date Incorporated:
  State
  Date Incoporated (MM/DD/YYYY)

• Type of Business *
  Resale Taxable Wholesale Distributor Lighting Dealer/Showroom Retail Manufacturer Service Other
  Describe your business:

• Bank Name *
• Street Address 1 *
• Street Address 2
• City *
• State *
  XX
• Zip *
  #####-####

• Please enter three credit references along with a fax number for each reference.

• Reference Name / Fax Number *
  Company Name
  ###
  ###
  ####
• Reference Name / Fax Number *
  Company Name
  ###
  ###
  ####
• Reference Name / Fax Number *
  Company Name
  ###
  ###
  ####

We have read the terms and conditions of sale and agree to comply.

• Name of Company Officer *
  First
  Last
• Title *