Distributor/Customer Information Form

Become a Dealer

Become a Dealer

Term 2005 - 2020 must be filled out completely and printed on company letterhead in order to be processed)

San Dimas,USA

+1 909 999-5555

Name of entity:*
Required Field Name of entity not valid
Address Of Your Main Location or Headquarters:*
Required Field

Years in Business:*
Required Field Years in Business not valid
Website address:
Required Field Website address not valid
Main email address:*
Required Field Main email address not valid
Worldwide Locations of Your Branch Offices*
Required Field Country not valid
A list of worldwide country locations or places where you ship the goods (Final Destination).
Required Field

Names and titles of entity’s ultimate parent company and individuals with controlling ownership:
Required Field

Names of entity’s subsidiaries if any
Required Field

Names of Entity’s Directors, Senior Management, CFO/CEO, President, Treasurer, General Managers :
Required Field

Contact person, phone and fax of Three Business References (e.g. Other U.S. Companies):
Required Field

Record of any Penalties or Proceeding Under U.S Export or Sanction Laws:
Required Field Record of any Penalties not valid
Any other relevant information :
Required Field

Required Field
Required Field