Return via Fax to: 615-206-3499 or Email to:

Partners or Officers
Name Title Home Address City State Telephone
Trade References Account # Telephone Fax
Alliance Distribution Partners does not sell to end users. Consequently, a Blanket Certificate of Resale accompanies this application. This application must be signed by an officer or principal of the company in order to be processed. By your signature below, you grant us permission to verify the information with the references listed. Additionally, this acknowledges acceptance of Alliance’s TERMS AND CONDITIONS attached to this form.

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615.206.3500 • 888.363.5913 • Fax 615.206.3499
539 North Belvedere Drive
Gallatin TN 37066