BetcoLink Associate Distributor Program Approval Form - Part 2 of 2

Approval Form

BetcoLink Associate Distributor Program
Today's Date

MonthDayYear
Distributor General Information
Distributor*
Distributor Address*

Street Address

Street Address Line 2

CityState

Zip Code
Distributor Phone*
Distributor Website (if none, enter N/A)*

Distributor Contacts
President / Owner*

First NameLast Name
President / Owner Phone*
President / Owner Email*
example@example.com
Sales Manager*

First NameLast Name
Sales Manager Phone*
Sales Manager Email*
example@example.com

Distributor Details
Number of years in business*
Geographic distribution area (please be specific)*
Number of locations*
Distributor type*
Number of sales representatives*
Market focus*
Please provide the address(es) of all your locations, if applicable

Chemical Suppliers
Please provide the name(s) of your chemical supplier(s). Enter N/A if not applicable.*

Powered Equipment Suppliers
Please provide the name(s) of your powered equipment supplier(s). Enter N/A if not applicable*

Dispensing Equipment Suppliers
Please provide the name(s) of your dispensing equipment supplier(s). Enter N/A if not applicable*
Number of laundry / warewash service technicians*

Distributor Purchase Information
Estimated annual chemical purchases*
Estimated annual powered equipment purchases*
Estimated annual laundry / warewash purchases*
Total estimated annual purchases

Wholesaler / Redistributor Information
Wholesaler / Redistributor Company Name*
Sales Representative*

First NameLast Name
Sales Representative Email*
example@example.com
Sales Representative Phone*

Opportunity Details
Please enter details regarding this opportunity. *
Once you click on submit, this form will processed and evaluated for approval.

A Betco representative will contact you soon with the status of your request.
Should be Empty: