Online Application for Distribution

Company Name	*
Address	*
City St Zip	*
Phone	*
Fax

Purchasing Agent	*
Sales Manager
"Ship to" Address
City St Zip

Email Address	*
Website Address

Type of Business
Number of Employees
Number of Salespeople
Annual Sales
Sell Retail	Yes No

Do you have a minimum retail order requirement? If so, amount $
What markets for plastic polish do you serve?
How do you reach your customers? (e.g., Catalog Sales, Telemarketing, Direct Sales, etc.)
Catalog Circulation
Do you currently sell a Plastic Cleaner, Scratch Remover, or Polishing Cloth? If so, please list the product name and manufacturer
How did you first hear about NOVUS Plastic Polish?	*