Company Name:

Contact:

Title:

Office Address:

City:

State:

Zip:

Telephone:

Fax:

Email:

Website:

Showroom Address (if applicable):

City:

State:

Zip:

Showroom Fax:

Sales Personnel (W-2 Sales Employees Only-Do not include sub-representatives or administrative staff):

FORWARD APPLICATION ALONG WITH CHECK PAYABLE TO ULTRA FOR $400 ($200 INITIATION FEE, $200 ANNUAL DUES) TO:
MATT WEINBERG
TREASURER/VP
2 Lincoln Hwy
Edison, NJ 08820