DISTRIBUTOR ACCOUNT APPLICATION

1. Company Information

Legal Company Name *

Doing Business As (DBA) Name (if applicable)

Company Registration Number / EIN *

Business Type (Check One) *
CorporationLLCPartnershipSole ProprietorOther

If Other, please specify

Year Established *

2. Business Address

Street Address *

City *

State *

ZIP Code *

Country

3. Shipping Address (if different from above address)

Street Address

City

State

ZIP Code

4. Primary Contact Person

Full Name *

Job Title / Position *

Department *

5. Contact Information

Phone Number *

Fax Number (if applicable)

Email Address *

Company Website

6. Billing Contact (if different)

Name

Email

Phone

7. Shipping Contact (if different)

Name

Email

Phone