Information Request Form

If you are interested in receiving information about becoming an authorized ChannelBrite Dealer, please complete the form below and a sales professional from ChannelBrite headquarters will contact you to answer any questions that you may have. They will also further explain our dealer opportunity.

The completion of this form does not obligate you in any fashion.

Please complete the form in it’s entirety.

* Indicates mandatory fields
Title:
First Name: *
Middle Initial:
Last Name: *
Business Name: *
Address 1: *
Address 2:
City: *
State: *
Zip: *
Phone (day): *	(xxx-xxx-xxxx)
Phone (evening):	(xxx-xxx-xxxx)
Phone (additional):	(xxx-xxx-xxxx)
Fax number:	(xxx-xxx-xxxx)
Email: *
Have you seen our lighting system?
How did you first hear about ChannelBrite? *
What is your current position, title, job duties and responsibilities? *
What are your first, second and third choices of locations of your ChannelBrite Dealership?
First Choice: *
Second Choice:
Third Choice:
Comments/additional info: