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1. Partnership Application Form
Purpose
Thank you for your interest in becoming an authorized partner. Please fill out the application
form below. We will follow up with you after we review your application.
Please indicate how you would like to partner with us:
Distributor Manufacturer Agent
Partnership Application Form
Company Contact Information
Company Name:
Address: City:
State: ZIP: Country:
Tel: Fax: E-mail:
Website Address:
Owner/President’s Name:

2. Company Background
Yrs. in Business: Total Revenues:
# Employees: # Offices: # Sales People:
Industry/Industries Serviced: # Customers:
Geographic Areas Serviced: Public or Privately Owned:
Avg. Annual Revenue: $0 – $1M $1M - $5M >$5M
Competition
List your top 4 competitors, by geographic area and product line:
1.
2.
3.
4.
Familiarity with Our Products
How long have you been familiar with our products?
0 – 2 Years 2 – 5 Years 5+ Years
What other products do you currently carry?
1.
2.
3.
4.

3. What other qualifications do you have that will enable you to sell our products?
Answer:
What are your top 4 product lines by sales revenue, and for how long have you been a
distributor for each of these product lines?
Manufacturer: Product Line: Yr Revenue: Length of Relation:
Manufacturer: Product Line: Yr Revenue: Length of Relation:
Manufacturer: Product Line: Yr Revenue: Length of Relation:
Manufacturer: Product Line: Yr Revenue: Length of Relation:
Marketing Plans:
How do you intend to market our products to your potential and existing customer base?
Answer:
Please attach a copy of your marketing plan.
Sales Estimates:
Please provide your best estimate for the annual revenue you expect to sell per year for each
product line:

4. Product Line 1.
Product Line 2.
Product Line 3.
Product Line 4.
Consent
I hereby consent to the verification of any or all of the information above:
Name of Applicant:
Company:
Title:
Signature Date