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Last Name *

Company/School Name *

Street Address *

Address 2

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Town / City *

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Phone *

Please Specify * Esthetician Cosmetologist Business Owner Student

Aesthetic License # or Student ID # *

Sales Tax Certificate Please upload your Sales Tax Certificate. (png,jpg,jpeg,pdf)

License Expiration Date

Tax-Exempt Select if Claiming Tax Exempt Status on Retail Items and you are located in CA or CO

Liability Insurance Please upload Liability Insurance. (png,jpg,jpeg,pdf)

Student Proof of Enrollment If you are a student, please upload your proof of enrollment documentation for review.

Graduation Date Please enter your estimated graduation date.

How did you hear about us? * Internet Referral School Social Media Tradeshow Other

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