Distributor Application

All fields in RED are required:

Company Name:

Company Principal:

Title:

First Name:

Last Name:

Address:

City:

St:

Zip:

Country:

Phone Number:			Ext.
()	-

Fax Number:
()	-

Email Address:

Geographic Servicing Area:

Approximate Annual Sales Total:
(e.g., Enter 1,500,000 not 1.5M)

Approximate Annual Sales:
(Jan/San)

Approximate Annual Sales
(Other Products)

Years in business:

No. of outside salespeople:

List your top suppliers:

Paper Products:

Can Liners:

Chemicals:

Equipment:

Do you have a web site?Yes No

If so, please list:

Are you aware of any other Distributors who might be interested in this opportunity?Yes No

If so, please list:

Are you a member of any other Buying Group(s)?Yes No

If so, please list:

Distributors

45662 Terminal Drive
Suite 200
Dulles, Virginia 20166
Tel: 800.229.9541
Fax: 703.480.5096