When Complete Save and Print Then Send Via EMAIL To: Or Via FAX at 281-292-2860

Sales Channel Registration

Date: Company Information

Company Name:

Billing Address:

Shipping Address:

Phone: Fax: Email: Web Page:

Sales Distributor Jobber/Contractor OEM Representative

Financial References Company Name Contact Name Phone Number Email Address

Territory Description

Shipping Restrictions or Requirements:

Sales Channel Registration

Management Staff: (Include Email and Cell Phone) Name Cell Phone Email Address Managing Director Financial Director Technical Director Chairman

Outside Sales Staff: (Include Email and Cell Phone)

Name Cell Phone Email Address

Inside Sales Staff: (Include Email and Cell Phone)

Name Cell Phone Email Address

Bank Details for Transfers by Detcon into Company Account (Detcon pays money into Distributors account in the form of destination commission. This is accomplished by wire transfer (if applicable) into your account therefore swift account and bank details are required.)

Bank Name Account Number Registered Name of Account Holder

Address Swift Code Bank Address

Other – IBAN Code

Submitted by: Date:

Region:

When complete save and print then send via EMAIL to: [email protected] or via FAX at 281-292-2860

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