DISTRIBUTOR/DEALER APPLICATION FORM
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INTERNATIONAL L.L.C.
COMPANY INFORMATION SUBMITTED INFORMATION IS SECURED. PLEASE READ OUR PRIVACY POLICY. *ALL MARKED FIELDS ARE REQUIRED FOR DEALER CONSIDERATION Name of Person/Company that referred you to us? *Country: *CompanyName: *Owner/CEO: *Tax ID# *Address/Street: *City: *State: *Postal Code: *Telephone: *Fax: *Email: *Your Name: *Title: *Company Web Site: *Company Information *Date of Inception: *Number of Locations: *Primary Business: *Secondary Business: *List products that your company sells/represents: We require a credit card on file for all orders. The card will be charged when your order ships.! *Credit Card Type: Number: Expires: Three Digit Security Code: *Business References *List at least one business reference/client that we may contact regarding the information that you have supplied on this application: #1 Contact Name: *Company: *Telephone: *Fax: *Email: *Web Site: #2 Contact Name: Company: Telephone: Fax: Email: Web Site: All Other Comments: A password to access the distributor pricing list and order form will be e-mailed to you upon approval. Save this password in a secure location. Your password is confidential and sharing or disclosing it to non authorized persons is prohibited and is cause for dealer termination. The Delia Tactical Team
