Questionnaire for Wholesale Account Setup

First Name

Last Name

Company Name

Which products are you interested in? -- Which products are you interested in? --420 ProductsSafeticide ProductsSafeguard ProductsMultiple Products

Years in the business -- Years in the business --1-2 Years3-5 YearsMore than 5 Years

Company Address

Company Website URL(s)

State(s) of interest

Number of Employees -- Number of Employees --1-56-1011-20More than 20

Do you have a brand? -- Do you have a brand? --YesNoWe are in the process of creating a brand

Your brand and URL Link

Do you have retail locations? How many? -- Do you have retail locations? How many? --No Retail Locations12345More than 5More than 10More than 20

What is the size of your sales force? -- What is the size of your sales force? --1-3 Sales people4-6 Sales people7-10 Sales peopleMore than 10 Sales peopleWe do not have a Sales forceWe are creating a Sales force now

Distribution Capabilities -- Distribution Capabilities --We currently distribute to 1-10 stores/outletsWe currently distribute to 11-20 stores/outletsWe currently distribute to 21-50 stores/outletsWe currently distribute to more than 50 stores/outlets

Other Distribution Information and, or capabilities we should know about

Contact Phone

Alternate Phone

Email

Referral and Confidential Information: Referral and Confidential Information: I have been referred by the individual(s) as listed within the ADDITIONAL MESSAGE and INFORMATION noted below and herein.

I understand that the information provided by me herein shall remain CONFIDENTIAL and only to be used for determining eligibility for wholesale account.

Additional Message and Information