ECOBOND® - Distributor Application

ECOBOND® - Distributor Application
Name*

First NameLast Name
Title*
Phone Number*

Area CodePhone Number
Fax Number*

Area CodePhone Number
E-mail*
Website Address*
reply to email
Company Information
Legal Company Name*
Doing Business As*
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Current Business Structure*
Year Established*
Number Of Facilities*
Federal Tax ID
DUNs Number
Distributor Last Year Revenue
Distributor Territorial Market Share*
Insurance Certificate for Doing Business

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Expected Monthly Volume Selling ECOBOND®*
1st Year Expected Revenue Selling ECOBOND®*
Expected Margin*
Origin of Ownership*
Facility Information
Facility Footprint sq. ft.*
Able to accommodate walk in or will-call customers*
Have or Willing to Acquire a Paint Mixer (1 & 5 gal)*
Willing to ship 1 and 2 day delivery*
Forklift and Warehouse Space for Overstock*
Tinting Capability*
Additional Information:
Should be Empty: