Distributors – APPLICATOR TECHNOLOGY, INC

COMPANY INFORMATION
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Tax I.D. Number*
Resale Number*
Years in Business*
Please enter a number from 1 to 100.
OWNERSHIP INFORMATION
Type of Business*
- Corporation
- Partnership
- Sole Proprietorship
Have you incorporated in the last 12 months?*
- Yes
- No
Principal #1 Name*
First Last
Principal #1 Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Principal #1 Email*
Principal #1 Phone*
Principal #2 Name
First Last
Principal #2 Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Principal #2 Email
Principal #2 Phone
Principal #3 Name
First Last
Principal #3 Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Principal #3 Email
Principal #3 Phone
FINANCIAL INFORMATION
Bank Name*
First Last
Bank Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Bank Phone*
REFERENCES
1. Business Name, Address, Phone, email, & Fax*
2. Business Name, Address, Phone, email, & Fax*
3. Business Name, Address, Phone, email, & Fax*

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