The following information will be used to consider the applicants request to become an Authorized Distributor for Grease-CONTROL.. Company with annual sales under $1,000,000 are required to complete the "Individual Information" portion of this application.

INDIVIDUAL  INFORMATION

Applicants Name                                    Home Address:                       City, State, Zip

Phone No.,                                               Fax No.,                                    Email Address:

Social Security Number                                                                            Date Of Birth:

Personal Annual Income:                       Asset Net Worth:                  Rent,  Or Own Your Home:

BUSINESS INFORMATION

Company Name                                                   

Street Address

City, State, Zip

Phone No.:

Fax No.:

Tax ID #:                                                                 

Tax Resale No.                                                           

Business Type: (Corporation,  LLC, Partnership,  Sole Proprietor Or Other)   

Years In Business:               Type Of Business/Industry:                                 Annual Gross Sales:               

No. Of  Sales Personnel:                 

No. Of  Service Personnel:                       

Total Employees:                 

What type of product(s) or services  do you currently provide? 

The Industry you are currently servicing or selling to:                               Total of Customers:

Bank Name:                                    Address:                         

Phone:                                              Bank Rep.:                                  Business Account No                       

Please list name of your business insurance company/underwriter              Policy No.

Name of Agency                             Contact Agent:                                        Phone:

Please list two business trade references.  You must include contact names and phone numbers:

Reference #1

Contact/phone

Reference #2

Contact/phone

What state(s) or providence are you selling to now?

Expected volume in purchases? (In US Dollars)

Monthly:

Annual:

All applicants that are applying to become an Authorized Distributor are required to complete the above application and submit it to Grease-CONTROL, Inc. for consideration.  No individual or company will be authorized to sell or promote Grease-CONTROL products until final approval is received in writing by Grease-CONTROL. All applicants must provide proof of insurance. Upon acceptance and approval.  The above information is true and accurate to the best of my knowledge. I  acknowledge that if any of the information provided in this application is found to be false, consideration to become an Authorized Distributor may be denied. By submitting this application I agree to allow Grease-CONTROL, Inc. to process any portion of the above information necessary. This might include calling applicants references, bank, insurance company.  Applicant agrees to allow Grease-CONTROL, Inc. to run a credit report on you and/or your business. All information provided is confidential and will be used for consideration to become an Authorized Distributor.