| Please complete the form below to become a
distributor. |
| Bold fields are
required |
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Contact
Name: |
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Title: |
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Company Name: |
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Address: |
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Address (cont): |
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City: |
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County: |
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State /
Province: |
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Country: |
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Zip / Postal
Code: |
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Phone: |
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Fax: |
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Email: |
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Choose
Area(s) of Interest |
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Residential Wells |
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Municipal Wells |
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Irrigation Wells |
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Municipal Treatment |
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Agricultural Treatment |
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Industrial Treatment |
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Cooling Towers |
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Wastewater Treatment |
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Reflection Pools/Decorative
Ponds |
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Swimming Pools/Spas |
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How long have you been working in
the your field of
interest(s), and in what
capacity? |
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List those products and
manufacturers that you currently
represent. |
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Describe your market
focus. |
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Describe your
relationships with your
manufacturers. |
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Do you currently hold any
industry certifications or licenses? If so, please
list them. |
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Are there any specific
accounts that you currently sell to? (Please
List) |
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Are there any specific
geographic territories that you wish to work in or currently
cover? |
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How often do you visit
your accounts in person? |
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How long have you or your
company been in this business? |
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Do you have any lines
that currently compliment or compete with ours? Please
specify. |
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What specific water
treatment problems are you or your market participants
currently working on to correct or regulate?
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What is it about our
products that encouraged you to contact
us? |
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Describe your plan to
introduce our product(s) in your market.
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What do you consider is
the minimum sales volume you need to justify representing our
line? |
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Please provide 3 industry
references that we may contact. |
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Please provide at least 3
financial references. |
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Is your interest in countries other
than USA? |
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Yes |
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No |
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For potential foreign or
export distributors... Are you interested in becoming a
partner and investor for distribution in your country of
interest? If so, please expand. |
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For potential foreign or export
distributors... What specific resources will you commit in
establishing a company in your country? |
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Additional Comments: |
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