Distributor Application Form

215 - 3007 Kingston Rd, Toronto ON, M1M 1P1 | TEL: (416) 289-4740 | FAX: (416) 289-7291

Application to Become a Distributor

Complete this application to initiate the process to become a distributor.
All fields are required.

Registered Company Name:
Trading Name:
Contact Information:
First Name:		Last Name:
Postal Address:
City:
State:		ZIP:
Country:
Phone:		FAX:
Manager Email:
Website:
Business Information:
Business Type:	Corporation LLC Partnership Sole Propritership Other
Years in Business:		ABN:
Business Hours:		Number of Employees:
Is your company a distributor for other Spill Control Products? Which Products?

What markets does your business target?

Prefered Payment Method:
Estimated Monthly Purchases in US Dollars:
Trade References:
1. Company:		Contact Name:
Phone:		Email Address:
2. Company:		Contact Name:
Phone:		Email Address:
Additional Information:



	Sales, Canada ABSOLUTE SORBENT TECHNOLOGIES 3007 Kingston, Ste 215 Toronto, Ontario M1M 1P1 Tel (416) 289-4740 \| Fax (416) 289-7291 E-mail: i...@absorbentech.com




	Sales, United States OMNI Safety, Inc. 730-16 Milford Road E. Stroudsburg, PA 18301 (570) 421-8048 E-mail: Omni...@verizon.net> Website: www.omni-ajax.com