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.


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:


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


Reference #2


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

Expected volume in purchases? (In US Dollars)



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.