Blue Ocean® Projection Screens | Reseller Application Form

Reseller Application Form

Please fill out the form below and click submit to apply to become a reseller of Blue Ocean® Projection Screens. All fields are required. If a question does not apply to you, please mark it "N/A", as this form will not submit if any field is left blank.

Or print the PDF application and fax it to us.

Note: Please Provide Resale Tax Certificate Separately with Signature by PDF, Fax or Mail.

E-mail Address: accnts@usnippura.com

Fax Number: 704-561-9196

Mailing Address: U.S. Nippura, Inc. | 3611 Tryclan Dr. | Charlotte, NC 28217

Company Information

Company Name:

Address 1:

Address 2:

City:

State / Province:

Zip / Postal Code:

Country:

Phone:

Fax:

Website:

In Business Since:

Contacts

Primary Contact:

Title:

Phone:

E-mail:

Sales Contact:

Phone:

E-mail:

Technical Contact:

Phone:

E-mail:

Billing Account Payable:

Address:

Phone:

E-mail:

Sales orders and invoices are sent in PDF form via email unless otherwise instructed. Documents will be sent to the Primary Contact if no Billing Contact is given.

Corporate Information

Please indicate the category that most accurately describes your company

Pro AV Home Theater Other

Please provide a brief summary of your company:

Company FED Tax ID#:

Please Provide Reseller Resale TAX Certificate Separately with Signature by Separate PDF / Fax / Mail

Bank Information

Bank Name:

Bank Contact:

Address:

City:

State / Province:

Zip / Postal Code:

Phone:

Fax:

Officer Name / Title:

Signature of Officer:

Date:

U.S. Nippura, Inc. | 3611 Tryclan Dr. | Charlotte, NC 28217 | T: 704-561-9191 | F: 704-561-9196

Blue Ocean® is the registered trademark of Nitto Jushi Kogyo Co., Ltd.