Join Our Team - Dealer Application

Join Our Team - Dealer Application

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Applicant's Organization

Company Name:

Contact Person:

Your email address will be used as your username to access the special portion of our website.

Email:

Please choose a password of more than 6 characters that you will use to login once approved in our system.

Password:
Confirm Password:

Address Line 1:

Address Line 2:

City:

State:

Zip:

Main Phone #:

Fax Number #:

Cell Phone #:

Date and Place of Establishment:

Licensed to do business in:

Operations Describe, briefly the nature and history of applicant’s business:

Product lines or services presently handled. Include manufacturer, state, products and approximate U.S. Dollar sales for the latest year:

Principal individual(s) who have wastewater related licenses and/or experience. Include years of experience, license type, and license #:

General Background List the trucks your company runs (how many and what types):

Market Information Desired territory (list counties):

Financial References

List four references, including all banks and major primary suppliers with which your company maintains a relationship.

Firm Name	Address	Principal Contact	Phone

Type of Business:

	Proprietorship
	Partnership
	Corporation
	LLC
	Other:

What market(s) are you focused on? (Check all that apply)

	Residential
	Commercial

What do you provide to your customers? (Check all that apply)

	We precast
	We install plants
	We perform maintenance or repairs
	We sell chemicals and accessories
	We offer pumping service
	Other