Brooking Industries Ltd.

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Your One Stop Emergency Vehicle Shop.

Distributor Form

Please fill out all of the information requested.

Company Name

Date

Billing Address		Shipping Address

Address 1		Address 1
Address 2		Address 2
City		City
State		State
Country		Country
Zip		Zip
		Type

Prefer to receive Invoices via:

Telephone:

Fax:

E-Mail address for marketing
E-Mail address for accts. payable
E-Mail address for purchasing

Marketing Contact

Accts. Payable

Principals 1.
2.

Is the company a

Other

Years in Business
No of Employees
Annual sales

Bank Reference: Name

Acct. Mgr.
Phone:

Federal Tax ID no.
State resale cert. no

Please fax or e-mail a copy of your current state resale certificate.

Is the company an
Web site	http://

Do you participate in local bids? (if affirmative select type)

Trade References

Name of Company:		Accounts Receivable Contact:
Accounts Receivable Phone #:		Accounts Receivable Fax #:
Years Doing Business With:

Name of Company:		Accounts Receivable Contact:
Accounts Receivable Phone #:		Accounts Receivable Fax #:
Years Doing Business With:

Name of Company:		Accounts Receivable Contact:
Accounts Receivable Phone #:		Accounts Receivable Fax #:
Years Doing Business With:

Print Name of Signatory

For (Company Name)

By submitting this application the prospective customer herein agrees that if approved as a dealer or distributor that they will remit payment in a timely and orderly fashion within the terms provided which are 30 days net.

Should your account be in arrears more than two invoice cycles you will be asked to sign a credit card authorization form allowing Brooking Industries, Inc. to charge whatever balance is due the company (Brooking), 45 days after the issue date of any past due invoice.

By typing my name below, I hereby authorize Brooking Industries, Inc. to review check my credit references and any other pertinent information as to its accuracy provided by me in this dealer/distributor application.

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