BECOME A DEALER

If you are interested in becoming an authorized Assura Dealer complete the form below.

Name
First Last
Business Name*
Phone*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Type of business or company*
Company Website URL
Does your facility have a warehouse/showroom?*
- Yes
- No
How many years has your company been in business?*
Can you accept tractor trailer delivery?*
- Yes
- No
Are you willing and able to service the products you sell?*
- Yes
- No
Previous Year's retail sales volume?*
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