Co-op Authorization Form

Please complete the fields below. Your Manufacturer(s) will receive a copy of your request and we will follow up with details about your Co-op Funding for advertising.

First Name *

Last Name *

Job Title *

Business Contact Information

Business Name *

Address *

City *

State *

Zip *

Email *

Phone *

Brand 1 Manufacturer / Distributor Contact Information

If you only have 1 Manufacturer or Distributor, only complete Brand 1. This form can accommodate up to three brands. If you have additional please email the details to [email protected].

Manufacturer 1 *

Contact First Name *

Contact Last Name *

Contact Phone *

Contact Email *

Your Customer # with Brand Manufacturer or Distributor *

Brand 2 Manufacturer / Distributor Contact Information

Skip if you do not offer products from multiple brands / manufacturers.

Manufacturer 2

Contact First Name

Contact Last Name

Contact Phone

Contact Email

Your Customer # with Brand Manufacturer or Distributor

Brand 3 Manufacturer / Distributor Contact Information