New Dealer Registration Application

Company Name

DBA or Tradename

Company Name

Street Address

Would you like to receive product catalog, price lists and literature to this address?

City

State/Province

Country/Region

9 digit ZIP code / Postal code

Phone number

Same address as Billing

Company Name

Street Address

Would you like to receive product catalog, price lists and literature to this address?

City

State/Province

Country/Region

9 digit ZIP code / Postal code

Phone number

Owner

First Name

Last Name

E-mail address

Business Information

Website

Business Entity Type Corporation Partnership Sole Proprietorship

Are you affiliated with a parent company, buying group, or national account? Yes No If yes, with whom? (Please include the address)

How did you hear about Safco?

What products are you interested in?

Is this product for your own use? Yes No

Is this a bid situation? Yes No

Which industry wholesalers/manufacturers are you currently buying from?

Do you accept partial shipments? Yes No

Would you like your order acknowledgment sent by email or fax? Email Fax Number Please enter the email address or fax number below.

Would you like your invoice sent by email or fax? Email Fax Number Please enter the email address or fax number below.

*Please mark the percent of business you do in each market. Please do not exceed 100%

Janitorial Distributor %

Art and Engineering %

Export Distributor %

Industrial Distributor %

Mail Order %

Mass Marketer %

Online Reseller %

Office Furniture Dealer %

Office Products Distributor %

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I have read the Application Terms and Conditions