Please complete the form below to start the process of becoming part of the Xarisma reseller team.

Company Info

Company Name (required)

First Name (required)

Last Name (required)

Job Title

Email (required)

Phone Number (required)

Fax Number

Web Address


Address 1 (required)

Address 2

Address 3

City (required)

State (required)

Zip (required)

Country (required)


How did you hear about Xarisma?

How would you describe your business?

What product(s) are you interested in?

What is your approximate annual purchase volume on these types of products?

If you are already working with a Xarisma representative, please list his/her name.

Billing Email Address

Xarisma emails all invoices. If these fields are left blank, the email will be sent to the primary contact on each order. If you would like all invoices to go to a specific contact, please complete the “Billing Email Field”. If you’d like to cc a contact (in addition to the default contact or Billing Email contact), please complete the “Billing CC Email” field.

Billing Email

Billing CC Email

Shipping Account Info

Xarisma is happy to ship on our customers’ shipping accounts at their request. If you would like us to use either your UPS or FedEx account, please complete the following fields. Otherwise, you may leave them blank.

Company Name

Address 1

Address 2





FedEx Billing Account

UPS Billing Account