Reseller Application Form

Company Name:*

Billing Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Shipping Billing Method

Freight Collect Account Number: Prefered Carrier:

Contact:*

Phone:*

Email:*

Email To Send Invoice:*

Email To Send Shipping Confirmation:*

Website:*

How long have you been in business?*

Are you privately held or publicly traded?*

How big of a warehouse do you have for stocking product?*

What product that we manufacture are you most interested in at this time?*

What is your anticipated monthly or yearly purchase volume of this product?*

Do you have a website and an online catalog?*

What industries that you service, make up the majority of your business?*

What geographical areas do you service?*

Do you have internal and/ or outside sales people?*

What other products that we manufacture might you be interested in?*

Will you be drop shipping at any time?*

How did you hear about our products (were you referred to us by a current customer)?*