Requestors Full Name (required) Requestors Company Name (required) Requestors Full Email (required) STATE OF RESIDENCE AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingOutside the United States / Other Location Does your company have Liability Insurance? YesNoInsurance Pending Are you an manufacturer? YesNo Are you a distributor? YesNo Specify the request(s) - check all that apply Request - I would like to distribute my product(s) to the My Deme, Llc. b2b communityRequest - I would like to sell overstock inventory to the My Deme, Llc., communityRequest - I would like to sell liquidation lots to the My Deme, Llc. b2b communityRequest - N/A or Other Listing Disclaimer: By submitting this form, I hereby certify that the information entered into this form is complete, accurate, and up-to-date, and that I am the consumer who is the subject of the request or have been authorized by that company to act on his/her behalf, as indicated above. I understand that it may be necessary for My Deme, Llc. companies to verify the identity of the consumer and/or authorized agent for this request, and additional information may be requested for this purpose. To continue, type the characters you see in the picture. The picture contains four characters. Δ
