New Customer Application Form
*denotes required field
Company Name*:
d/b/a/ Company Name:
Your Name*: Your Title*:
2nd line:        
City*:   State/Province*:      
Country*:   Zip/Postal Code*:      
Phone Number*:   Fax Number*:      
Website Address:
Resale Certificate#*            
Business Type (choose all that apply)*   Products Of Interest (choose all that apply)*
 In Store Retailer    Cellular      
 Online Retailer    Laptop      
 Domestic Distributor    Cellphone/PDA      
 International Distributor    Cordless Phone      
 Repair Center    Digital Camera/Camcorder      
 Manufacturer    Survey      
 Corporate Buyer    Sealed Lead Acid      
 Government Institution    Two-Way/FRS      
Are you currently selling Empire Products? YES    NO   
If "YES", who is your supplier?  
Referred By*:
Please list your current vendors*:            
  What is your level of interest at this time?*
  Preferred payment type*:
    Open Account requires credit approval and
a minimum purchase of $500 monthly
Additional information or comments you'd like to add:
To help prevent spam, Follow the instructions below to prove you are not a robot. Then Click on Submit            

By clicking [Submit] you hereby authorize Empire Scientific to use all the information you provided to perform the necessary background and credit checks concerning your business. This information will be used soley ito assist the determination of your business' ability to become an approved Empire customer. All information supplied will remain confidential between your company and Empire, and none of this information will be resold or made public by any means. We reserve the right to keep this information in our files for potential future contact with you and/or your business. Misleading or intentionally incorrect information will force us to bar you and your company from ever being an Empire reseller, as we pride ourselves on the high level of professionalism and integrity we expect from ourselves and all those who handle our products. This is only an application for becoming a reseller; there are no guarantees expressed or implied at this time.