Reseller Application Form

DISTRIBUTOR APPLICATION/ENROLMENT FORM

1. Basic Information

ORGANISATION (PERSONAL NAME FOR INDIVIDUALS): (required)

LOCATIONS ADDRESS (required)

TELEPHONES NOS: (required)

YOUR EMAIL (required)

2. BUSINESS INFORMATION

NATURE OF BUSINESS (required)

REGISTRATION STATUS (PLEASE TICK AS APPROPRIATE) (required)
SOLE PROPIETORSHIPREGISTERED BUSINESS NAMELIMITED LIABILITYPUBLIC LIMITED COMPANY (PLC)

3. DISTRIBUTION CATEGORY OF INTEREST

DISTRIBUTION CATEGORY OF INTEREST (PLEASE TICK AS APPROPRIATE) (required)
Reseller – Minimum order of 10 unitsDealer – Minimum order of 50 unitsSuper Dealer – Minimum order of 100 units

4. PRODUCT/SERVICE OF INTEREST

PRODUCT/SERVICE OF INTEREST (PLEASE TICK AS APPROPRIATE) (required)
Antixplosion Keg – 10 LitresAntixplosion Keg – 25 LitresAntixplosion Gas CylinderRetrofit Installation ProgramFamily First Fire Safety Devices

5. KEY STAFF DATA

NAME (required)

TEL NO (required)

DESIGNATION (required)

EMAIL ADDRESS (required)

NAME

TEL NO

DESIGNATION

EMAIL ADDRESS