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* Required Fields - Please include information in these fields.

Application for:	Distributor    Representative
Product Group:	Material Handling Holding Magnets Separation/Filters Printing Products
Company:
Name:*
Mailing Address:*
Shipping Address:
Day Phone:*
FAX:
E-Mail:
Resale Number:
Annual Sales Volume:
President:
Vice President:
Sales Manager:
Primary Inside Sales Contact:
No. Inside Salespeople:      No. Outside Salespeople:
Territory Covered:
Branch Locations:
Major Product Lines Carried:
Competing Line & Disposition:
List Major Customers Who May Use Bunting Products:
Branch Locations:
If you are going to be a stocking distributor, which products do you intend to stock?
Do you have a distributor catalog?
Will Bunting products be included?
Do you maintain a customer mailing list?
Number of names:      Can we participate?
What competing representation to the Bunting line is there in your trading area?
Catalog Select 1060 2200 3000 4000 4300 4500 5000 Amt:     Catalog Select 1060 2200 3000 4000 4300 4500 5000 Amt:
Catalog Select 1060 2200 3000 4000 4300 4500 5000 Amt:     Catalog Select 1060 2200 3000 4000 4300 4500 5000 Amt:
Catalog Select 1060 2200 3000 4000 4300 4500 5000 Amt:     Catalog Select 1060 2200 3000 4000 4300 4500 5000 Amt:
Sales samples requested. How many and what kind?
Other comments.
If distributor application, please list bank and credit references:
Bank Name:
Bank Address:
Bank Phone:
FAX:
Bank Officer:
Credit References
If approved, effective date of agreement
Completed By:
Date: