Dealer Application
   
 
       
Name of Applicant:
 
Position in Company:
 
Name of Company:
 
Office Address:
State:
Postal Code:
Country:
E-mail address:
Telephone:
Facsimile:
Postal Address:
State:
Postal Code:

Type of Company:
Proprietor/Partnership Private Limited Public Listed
Number of Years in
Operation:
 
Number of Staff:
 
Please describe your present business activity:
Paid-Up Capital:
Authorised Capital:
Business Turnover:
2003:  2002:  2001: 
Names of Agencies Presently Represented:
1 2 3 4
Do you currently handle any products similar to Central Vacuum Systems? If so, please state the type and manufacturer.