Enrollment

To enroll, please complete the form below. Your registration will be processed, and you will receive an email to create a password for your account.

First Name

Last Name

Company

Company Address

Company Address Line 2

City

State

Zip Code

Phone Number

Business Email

Website URL

Estimated Annual LIXIL Purchase Amount (American Standard, GROHE, DXV)

Please provide an estimate, your rebate will be based on your actual purchase total for the year.

Number of Employees

Plumbing Specialty

How did you hear about the program?

Sales Representative Name

Detail

Where do you purchase your LIXIL products from?

You must select at least one distributor. Make sure to select one and click the 'Add Store' button.

	Name

Make Check Payable To

Shipping Address

Shipping Address Line 2

Shipping City

Shipping State

Shipping Zip

Terms and Conditions