Dealer Application Form

 

 

 

Company Profile
Name of Firm
Address 1
Address 2
City
State
Zip/Postal
Country
Phone
Fax
E-Mail
We are set up as a:
Number of Employees
  Name & Home Address of Proprietor or of Partners
a. Name
Title
Address 1
Address 2
City
State
Zip/Postal
Federal Tax ID/Other #
b. Name
Title
Address 1
Address 2
City
State
Zip/Postal
Federal Tax ID/Other #
  If Corporation, Officers' Names:
President
Buyer
Payables
Date Business Established
How long at present location
Federal Tax ID #
Resale Number
Territory Requested
Estimated Qty. per year


 

 

Return to HomePage

© Copyright 1989 To Present Escan Technologies Corp. All Rights Reserved