Service Provider Application Form Twitter Company * Street Address * City * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Postal Code * Website * Contact Name * Email Address * Phone * Products * Other Group Affiliations * Luxury Products Group Base Rebate % * Is rebate available to Canadian members? * Yes No Is rebate figured on all products? * Yes No Products excluded from rebate How is rebate calculated on purchases? * What is your pricing discount structure to the Luxury Products Group Program? (Discount from list or multiplier) * Detailed list of any deductions to the above calculations Are payment terms regular? * Yes No Are payment terms special to Luxury Products Group? * Yes No List payment terms * List early payment terms if available Do you accept p-cards? * Yes No Company Representative * Title * VIEW LUXURY PRODUCTS GROUP DESTINATION SHOWROOMS Collection No. 1
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