Become A Distributor - safeHands® - Alcohol Free Hand Sanitizer

Company Name*

Name*

Email*

Phone Number*

Referred to SHDNE by

Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Shipping Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Accounts Payable Contact

First Last

Accounts Payable Email Address

Accounts Payable Phone

Accounts Payable Fax

Purchasing Contact

First Last

Purchasing Contact Email Address

Purchasing Contact Phone

Customer Service Contact

First Last

Customer Service Contact Email Address

Customer Service Contact Phone

Preferred Carrier

D&B Number

Rating

Organization Size/Number of Employees

Approximate Warehouse Size

Branch Locations

Geographic Areas Served

Telemarketing

Yes
No

Direct Sales

Yes
No

Number of Salespeople

Business Is (Corporation, Partnership, Proprietorship)

Name of Owner or Principal

First Last

Credit References

Credit Reference 1

Credit Reference 2

Credit Reference 3

Bank Name

Bank Contact

First Last

Bank Contact Phone

Bank Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Catalog

Yes
No

Preparer's Name

First Last

Preparer's Email Address

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