New Distributor Form

Billing Address:
Company Name:
Billing Address:
City:
State:
Zip:
Telephone (at this location):
General Fax (at this location):
Manager (at this location):
Title:
E-mail:
Invoice Fax (at this location):
Invoice Fax (to Attention):
Shipping Address (if different from Billing Address):
Company Name:
Street Address*:
City:
State:
Zip:
Telephone (at this location):
Fax (at this location):
Manager (at this location):
Title:
E-mail:
*Engineered Products Company will not ship to a P.O. Box
Business Profile
Are you the: Owner
Branch Manager
Location Manager
Counter Manager
Name:
Title:
Telephone:
Fax:
E-mail:
Person Authorized to Purchase
(at this location):
Title:
Telephone (at this location):
Fax (at this location):
E-mail:
Accounts Payable Contact
(at this location):
Title:
Telephone (at this location):
Fax (at this location):
E-mail:
Type of Business
(check all that apply):		 Corporation
Partnership
Sole Proprietorship
Distribution Center
Branch
Independent Location
Year Established:
Number of Employees at this Location: 1-19
20-49
50-99
100-249
500+
Estimated Volume at this Location:
Percentage of Commercial Sales:
Percentage of Residential Sales:
Percentage of Industrial Sales:
Percentage of Other Sales:
Specify:
Buying Group Affiliation/
National Group Affiliation:
Trade References
Company:
Contact Name:
Title:
Telephone:
Fax:
Company:
Contact Name:
Title:
Telephone:
Fax:
Company:
Contact Name:
Title:
Telephone:
Fax:
Sales Agency Information
Sales Agency:
Sales Agency ID:
Sales Representative: