Company Name

Country

Business Address

Zip Code

City

State

Phone

Fax

E-mail

Web Address

Owner

Primary Officer

List other authorized buyers for your company

Person responsible for Accounts Payable

Resale Tax #

Please attach copy of resale tax certificate

Trade References - Please list references that establish you as a distributor. Minimum three required.

1. Company Name

Phone

Fax

2. Company Name

Phone

Fax

3. Company Name

phone

fax

Describe your business and the method of distribution

*Dunn and Bradstreet #