Partnership Application Form

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

2. Company BackgroundYrs. 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 >$5MCompetitionList your top 4 competitors, by geographic area and product line:1.2.3.4.Familiarity with Our ProductsHow long have you been familiar with our products? 0 – 2 Years 2 – 5 Years 5+ YearsWhat other products do you currently carry?1.2.3.4. Company BackgroundYrs. 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 >$5MCompetitionList your top 4 competitors, by geographic area and product line:1.2.3.4.Familiarity with Our ProductsHow long have you been familiar with our products? 0 – 2 Years 2 – 5 Years 5+ YearsWhat 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 adistributor 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 eachproduct line: 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 adistributor 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 eachproduct line:

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