New Distributor Application form

   

Distributor Information

   
DISTRIBUTOR NAME :
DATE :
ADDRESS :
CITY :
PIN CODE :
COUNTRY :
PHONE :
FAX :
EMAIL :
COMPANY WEB ADDRESS :
PRINCIPAL CONTACT AND TITLE :
PRINCIPAL CONTACT'S EMAIL :
NUMBER OF SALESPEOPLE :
PURCHASING CONTACT :
   

REFERENCES AND BANKING INFORMATION

   

PLEASE PROVIDE THREE TRADE REFERENCES :

1 .
2 .
3 .
   

PLEASE LIST BANK INFORMATION :

   
BANK NAME :
BANK PHONE NUMBER :
BANK CONTACT NAME :
BANK ACCOUNT NUMBER :