Distributor Application Form

NAME OF COMPANY

ADDRESS

CITY

POSTAL CODE

COUNTRY

HOW LONG HAVE YOU BEEN OPERATING?

NUMBER OF BRANCHES (IF ANY)

HOW MUCH ARE YOU READY TO INVEST IN THIS BUSINESS?

AVERAGE MONTHLY TURNOVER FOR THE PART SIX MONTHS

Distributor's Authorized Representative/Manager's Particulars

FIRST NAME

LAST NAME

EMAIL ADDRESS

ADDRESS

CITY

POSTAL/ZIP CODE

COUNTRY

PHONE NUMBER

WHAT IS THE MINIMUM IN CARTON THAT YOU ENVISAGE PER MONTH?

WHAT AREA DO YOU INTEND TO COVER AS A DISTRIBUTOR/ SUB DISTRIBUTOR?

WHAT AREA DO YOUR WHOLESALER/SUB DISTRIBUTOR/CUSTOMERS COVER?

NAME OF OFFICER/INSTITUTION DISTRIBUTOR COMPLETING THIS APPLICATION

FIRST NAME

LAST NAME

ADDRESS

CITY

POSTAL/ZIP CODE

POSITION

PHONE NUMBER

DATE

HOW DID YOU HEAR ABOUT US?

SOCIAL MEDIA FRIEND