Distributor Application Form

Which products are you interested in? BothStat-X Condensed Aerosol SystemK-Series Kitchen/Galley Fire Suppression System

First Name*

Last Name*

Title*

Company*

Address

Telephone Number*

Email*

Website

Number of Employees

Industries you work in

Do you have employees that are certified to design and/or install fire suppression systems including certifications held from the recognised governing agency or entity? YesNo

Do you carry the following insurance coverage?

£10,000,000 Employers Liability YesNo

£2,000,000 Public and Products Liability (inclusive of efficacy cover) YesNo

Products you currently offer

Regions in which you market

How do you plan to market the product line if a distributor?

Estimated sales in Year 1 (no. of units)

Estimated sales in Year 2 (no. of units)

Comments or Questions: