First Name

Last Name

Job Title

Phone

Email Confirmation

Password Must be at least 12 characters and contain at least one lowercase character, one uppercase character and one special character.

Confirm Password

Secondary Email

Emails do not match.

Passwords do not match.

The password must be at least 12 characters.

The password must contain at least one uppercase character.

The password must contain at least one lowercase character.

The password must contain at least one special character.

All fields must be complete in order to proceed.

Company Name *

Company FFL *

Manager Name *

Company Address *

Company Address — Line 2

City *

State *

Zip *

Customer Number *

Your store's customer number can be found at the top of any Trijicon Invoice in the Information box.

Store Number

For retailers with multiple store locations operating under the same name, please enter the store number assigned to identify your store location.

All required fields must be complete in order to proceed.

What optic brands does your company sell?

Check all that apply

Burris Bushnel Eotech Leupold Nightforce Trijicon Vortex

Other

First Name Last Name

Company | Manager: Name
FFL#: xxxxxxxxxxxxxxxx

123 Address

City, State, Zip

Customer #: xxxxxxxxxxxxxxxx
Store #: xxxxxxxxxxxxxxxx

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