Reseller Application
Thank You for your interest in being a BRUGO Reseller. Please complet this online application and we will be in contact with you soon.
General Information
Company Name:
Doing Business As (Dealer/Distributor Name):
Address:
City:
State:
Zip Code:
Country:
Telephone Number:
Fax Number:
Email Address:
URL Address:
Parent Company (if affiliate/subsidary):
Address:
City:
State:
Zip Code:
Country:
Business Profile
Organizational Form:
Corporation
Incorporation State:
Incorporation Date:
Partnership
Sole Proprietorship
Federal ID No. :
D & B No. :
Years in business:
Accounts Payable Contact Name:
Accounts Payable Contact Phone:
Total Number of Employees:
Employees - Inside Sales:
Employees - Outside Sales:
No. of selling locations:
Current Annual Sales Volume $:
Previous Year Sales Volume $:
Next Year (Projected) Sales Vloume $:
Company Personnel
Owner / President:
Marketing Manager:
Accounting Manager:
Sales Manager:
Purchasing Manager:
Financial/Credit Information
Bank Name:
Type of Account:
Account #:
Address:
City:
State:
Zip Code:
Country:
Officer:
Bank Name:
Officer::
Acoount Number:
Telephone:
Name of Landlord/Mortgage Holder::
Phone:
Business operated from:
Commercial Building
Home
Own
Rent
Years:
If less than 2 years at current location:
Name of Previous Landlord/Mortgage Holder::
Phone:
Business operated from:
Commercial Building
Home
Own
Rent
Years:
Credit References
Company Name:
Contact Name:
Email Address:
Type of Business:
Address:
City:
State:
Zip Code:
Country:
Telephone Number:
Fax Number:
Acct #:
Company Name:
Contact Name:
Email Address:
Type of Business:
Address:
City:
State:
Zip Code:
Country:
Telephone Number:
Fax Number: