Dealer/Distributor Application

Do you have a VLTOR account?

Before filling out the application form below, please be sure to register first by creating a VLTOR account:

Register Here

Please fill out the application form below:

If you already have an account please proceed by filling out the form below.

    Your Name (required):

    Your Email (required):

    Important: Please use the same email that you registered with.

    Company Name (required):

    Street Address (required):

    City (required):

    State (required):

    Zip (required):

    Are you the Owner, CEO or Manager (required):

    Telephone (required):


    Company e-mail address (Leave blank if the same as personal email):


    Tax I.D. Number (required):

    Primary type of business (check one):

    Check all that apply:

    Select the price level for your opening order based on the following:

    Select one of the following: