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: