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Crystal Tip^®

Register Your Account

Please click on the appropriate icon for your professional status to begin.

Dental Professional

Affiliate

Technician Affiliate

Distributor

Distributor Rep

Register as

Affiliate

As an affiliate, or independent representative of Dental products, you are a valuable asset for us and we will reward you with outstanding commissions and incentives when you become a Crystal Tip^® Affiliate Rep.

* Indicates required fields

Please Fill Out The Form Below

Have Questions? Get In Touch

Personal Information

First Name*

Last Name*

Address*

Unit No. (if applicable)

City*

Country*

Postal Code*

State

Name Of Company*

Primary Contact

Phone Number*

Extension

Secondary Contact

Phone Number

Extension

Fax Number

Email Address*

Territory You Cover

Country*

State

Distributors/Dealers You Currently Work Directly With

Company Name

Contact

Phone

Company Name

Contact

Phone

Company Name

Contact

Phone

Company Name

Contact

Phone

Add Another Distributor or Dealer

List Top 5 Dental Products You Represent

Product Name

Product Name

Product Name

Product Name

Product Name

Do You Currently Represent A Disposable Syringe Tip?

Yes No

Brand Name*

Please Create Your Log In Credentials

Username*

Password*

Retype Your Password*

We recommend your password be at least 5 characters. It should be different from your username. Your email address must be valid. We use email for communication purposes (order notifications, etc.). Therefore, it is essential to provide a valid email address to be able to use our services correctly. All your private data is confidential. We will never sell, exchange or market it in any way. For further information on responsibilities of both parties, please refer to our "Terms & Conditions".

Yes, i have read and agree to the terms and conditions.

Register as

Technician Affiliate

Thank you for registering with us. As a technician affiliate you are a valuable asset for us and we will reward you with outstanding commissions and incentives when you become a Crystal Tip^® Affiliate Rep.

* Indicates required fields

Please Fill Out The Form Below

Have Questions? Get In Touch

Personal Information

First Name*

Last Name*

Address*

Unit No. (if applicable)

City*

Country*

Postal Code*

State

Name Of Company*

Shipping Address (Only If Different From Contact Information)

First Name

Last Name

Address

Unit No. (if applicable)

City

Country

Postal Code

State

Name Of Company

Primary Contact

Phone Number*

Extension

Fax

Email Address*

Territory You Cover

Country*

State

Distributors/Dealers You Currently Work Directly With

Company Name

Contact

Phone

Company Name

Contact

Phone

Company Name

Contact

Phone

Company Name

Contact

Phone

Add Another Distributor or Dealer

List Top 5 Dental Products you Represent

Product Name

Product Name

Product Name

Product Name

Product Name

Other Information

Do You Currently Represent A Disposable Syringe Tip?*

Yes No

Brand Name

Brand Name

Brand Name

Do You Currently Work With Any Dental Chair Manufacturers?*

Yes No

Name of Chair Manufacturer

Name of Chair Manufacturer

Name of Chair Manufacturer

Name of Chair Manufacturer

Have You Ever Previously Represented A Disposable Syringe Tip?*

Yes No

Brand Name

Brand Name

Brand Name

How Did You Hear About Crystal Tip^®?*

Please Create Your Log In Credentials

Username*

Password*

Retype Your Password*

We recommend your password be at least 5 characters. It should be different from your username. Your email address must be valid. We use email for communication purposes (order notifications, etc.). Therefore, it is essential to provide a valid email address to be able to use our services correctly. All your private data is confidential. We will never sell, exchange or market it in any way. For further information on responsibilities of both parties, please refer to our "Terms & Conditions".

Yes, i have read and agree to the terms and conditions.

Register as

Distributor

Thank you for registering with us. To become an authorized Crystal Tip^® Distributor, please fill out the form below.

* Indicates required fields

Please Fill Out The Form Below

Have Questions? Get In Touch

Company Information

Name Of Company*

Address*

Address

City*

Country*

Postal Code*

State

Shipping Address (Only If Different From Contact Information)

Name Of Company

Address

Address

City

Country

Postal Code

State

Contact Information

First Name*

Last Name*

Job Title*

Primary Contact

Phone Number*

Extension

Secondary Contact

Phone Number*

Extension

Fax

Email Address*

Marketing Department Contact

First Name*

Last Name*

Phone Number*

Extension

Email Address*

Accounting Department Contact

Phone Number*

Email Address*

Fax

Other Information

What Territory Does Your Company Cover?

USA FOREIGN

Please List Location Of Distribution Center(s)

USA FOREIGN

I Am A National Distributor

Yes No

Number Of Sales Representatives That Work For Your Company

Please List Top 3 Disposable Air/Water Tips You Currently Sell

Brand Name

Brand Name

Brand Name

Please Create Your Log In Credentials

Username*

Password*

Retype Your Password*

We recommend your password be at least 5 characters. It should be different from your username. Your email address must be valid. We use email for communication purposes (order notifications, etc.). Therefore, it is essential to provide a valid email address to be able to use our services correctly. All your private data is confidential. We will never sell, exchange or market it in any way. For further information on responsibilities of both parties, please refer to our "Terms & Conditions".

Yes, i have read and agree to the terms and conditions.

Register as

Distributor Rep

Thank you for registering with us. To become an authorized Crystal Tip^® Distributor Rep, please fill out the form below.

* Indicates required fields

Please Fill Out The Form Below

Have Questions? Get In Touch

Personal Information

First Name*

Last Name*

Address*

Unit No. (if applicable)

City*

Country*

Postal Code*

State

Name Of Distributor*

Shipping Address (Only If Different From Contact Information)

First Name

Last Name

Address

Unit No. (if applicable)

City

Country

Postal Code

State

Name Of Distributor

Primary Contact

Phone Number*

Extension

Fax

Email Address*

Territory You Cover

Country*

State

List Top 5 Dental Products You Represent

Product Name

Product Name

Product Name

Product Name

Product Name

Please Create Your Log In Credentials

Username*

Password*

Retype Your Password*

We recommend your password be at least 5 characters. It should be different from your username. Your email address must be valid. We use email for communication purposes (order notifications, etc.). Therefore, it is essential to provide a valid email address to be able to use our services correctly. All your private data is confidential. We will never sell, exchange or market it in any way. For further information on responsibilities of both parties, please refer to our "Terms & Conditions".

Yes, i have read and agree to the terms and conditions.