Dealership Form
Company Information
Company Name*

Contact Person*

Title*

Company Address*

City*

Province/State*

Country*

Telephone*

Fax
Email*

Address 2
City
Province/State
Country
Zip
Telephone
Email
Website
Business Information
Year of Establishment*

Sales*

Annual Growth*
%
Ownership Type*
LLC S Corporation
C Corporation PLC
Partnership Proprietary
Private Limited Public Limited
Other
Staff Strength*

Name of the Partners/Owners/Director*


(A.)

Telephone

Cell No.

(B.)
Telephone
Cell No.
(C.)
Telephone
Cell No.
Billing Address
City
Province/State
Country
Zip
Telephone
Fax
Type of Business


Distributor


Type of Products Offer
Current Supplier
Industry
Territory
Dealer/System Integrator


Current Supplier
Industry
Territory
Importer


Products
Current Supplier
Purpose
Distribution Project Basis
Territory
Manufacturer


Type of Products Offer
Industry
Territory
Shopping Address
City
Province/State
Country
Zip
Telephone
Fax
Purchasing Contact
Sales Contact
Name
Title
Email
Telephone
Fax
Cell No.
Name
Title
Email
Telephone
Fax
Cell No.
Technical Support
Accounts Payables
Name
Title
Email
Telephone
Fax
Cell No.
Name
Title
Email
Telephone
Fax
Cell No.
Tax-As Applicable
Credit Reference
TAX I.D.
GST No.
S.S. No.
CST No.
VAT/TIN No.
PAN No.
Other Tax ID No.
Applicable for US country only*


(A.)

Company Name
Contact Person
Telephone
Email
(B.)

Company Name
Contact Person
Telephone
Email
(C.)

Company Name
Contact Person
Telephone
Email
Filled By
Title
Select An ID & Password
Username*

Password*