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Distributor Application

Your Company's Name(Required)

Billing Address(Required)

Order Acknowledgement Email(Required)

Invoice Email

Phone

Fax

President/Owner

Company ID

Number of Years in Business

Number of Employees

Are you a reseller?

Yes

Type of Business

Anticipated annual sales volume (in US Dollars) of floats, alarms & panels:

What industries do you currently supply?

Who do you currently sell to?

What products do you currently distribute?

Type of credit requesting:

Estimated monthly credit:

Applying for a credit card account? Please skip to "Ship to Address".

Fill out this section only if the type of credit you are requesting is an Open Account or Prepayment

Please provide bank references:

Full Bank Name

Account Number

Address

Phone

Fax

Please provide trade references: (All three reference must be entered to complete this application)

Reference #1

Company Name

Contact Name

Address

Phone

Fax

Reference #2

Company Name

Address

Phone

Fax

Reference #3

Contact Name

Company Name

Address

Phone

Fax

Ship to Address

(for products that need to be shipped to a location different than the billing address provided above)

Name/Attn To

Phone

Address

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