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Distributor Application

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Principal Officers or Owners

Title

First Name Last Name

Email Address (e.g. john@doe.com) Cell Number

Current Address/City/State/Zip

Business Activity

Describe Company's Major Business Activity

Sales (US$)- Last Year & Current Year

Bank Name and Address

Two Business References: Name, Business Position, Number

Are you Currently a Representative, Dealer, or Distributor in our industry?

Describe Type of Products or Equipment Sold, Including Name Brands

Business and Experience Record

How Long Have You Been in (our industry) Business?

Are you currently an agent, representative or distributor for any other company that manufactures products similar? If yes, name companies

Do you own or contract with an outside service workshop/warehouse for stocking? If yes, give name and address of outside workshop/warehouse

If you do not have a service facility/stocking warehouse, are you willing to establish one for support of our products? If yes, when?

Please provide us with a preliminary indication of what marketing strategies you would use to market our products.

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$199.99 $139.99

5/5

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(866) 997-6225

support@energinseng.com

Distributor Application

Company Information

Principal Officers or Owners

Business Activity

Business and Experience Record

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enerGinseng Herbal Coffee Bag

enerGinseng Herbal Coffee Box

enerGinseng Herbal Coffee Case

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