Distributor Information Form

Company/Organization*
First Name*
Last Name*
Address 1*
Address 2
City*
Province/State
Country*
Postal/Zip Code
Telephone #*
Fax #
Email Address*

Please provide the following information regarding your organization, and sales activity.
1. In what sales territory does your organization operate?

2. What are the products that you already sell?

3. Do you represent other chemical manufacturers? Please list the ones you represent.

4. Who are your main competitors?

5. How many years have you been in business?

6. How many employees do you have?

7. What is the size of your warehouse facility? Is it suitable for chemical storage?

8. Please provide any other information that you feel would assist us in determining if a distribution agreement would be mutually beneficial.