Unity Coins

Apply to be a Retail Reseller of Unity Coins™

Please fill in the boxes & click "submit" below.

Items marked with an asterisk (*) are required.

Business Name:

First Name: *

Last Name: *

Title:

Email Address: *

Confirm Email Address: *

Mailing Address: *

Additional Mailing Address:

City: *

State/ Province: *

Zip Code/ Postal Code: *

Country: *

Phone (day): *

Fax:

Your web site on which you'll sell MyBarong products (if applicable):

Choose a password: *

Verify password: *

I have read & agree to the Terms of Agreement for Resellers:

Resale Certificate

By submitting this form, I hereby certify that:

I hold a valid Seller's Permit Number (enter it here):
I am engaged in the business of selling the following type of tangible personal property (i.e. Unity Coins, accessories):
I will resell the item(s) listed below (#4), which I am purchasing from MyBarong (the manufacturer/distributor of Unity Coins) under this resale certificate in the form of tangible personal property in the regular course of my business operations, and I will do so prior to making any use of the item(s) other than demonstration and display while holding the item(s) for sale in the regular course of my business. I understand that if I use the item(s) purchased under this certificate in any manner other than as just described, I will owe use tax based on each item's purchase price or as otherwise provided by law.
Description of property to be purchased for resale: