Distributor Application Form

 for Armstrong LiftMag™ lifting magnets

Note: All fields are required to be filled.

1. Contact Information:

     Contact Name:          Contact Title:  
     Phone Number:          Fax Number:  
     Email:               
 

2. Company Information:

    Company Name:              
    Address:                      
    City:                            
    Province/State:             
    Postal Code/Zip Code:   
    Country:                       
    Web Site:                   
 

3. Business Information:
    What Year Established:                  
    Number of Sales Employees:    
    Annual Revenue in US$:                 
    Distribution Territory:                 
    What are the main products you sell?
    Have you sold lifting magnets before?   yes no
    If yes, how many lifting magnets you sold last year?

4: Comments: