Authorized Protectowire Distributor Application

Phone

This field is for validation purposes and should be left unchanged.

Business Contact Information

Legal business name, addresses & contact details

Company Legal Name(Required)

Doing Business As (DBA)

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Shipping Address

(if different from mailing)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number(Required)

Company Website(Required)

Invoice Email(Required)

Preferred Shipping Method(Required)

Value Added Tax (VAT) # (EU only)

Contact Information

Key personnel and their email addresses

Primary Contact(Required)

First Last

Primary Contact Email(Required)

Sales Manager(Required)

First Last

Sales Manager Email(Required)

Purchasing Manager(Required)

First Last

Purchasing Manager Email(Required)

Accounts Payable(Required)

First Last

Accounts Payable Email(Required)

Billing Contact(Required)

First Last

Billing Contact Email(Required)

Shipping Contact(Required)

First Last

Shipping Contact Email(Required)

Additional Contact

First Last

Additional Contact Email

Company Background

Tell us about your business

What industry are you in?(Required)

How many years have you been in business?(Required)

What is you primary target market(Required)

Number of Sales Reps(Required)

Number of Engineers(Required)

Number of Offices / Locations & Where(Required)

Company Owner & Officers(Required)

Additional Details

Current distribution, products & interest in Protectowire

What companies are you an authorized distributor for?(Required)

What products are you currently selling?(Required)

Why are you interested in representing Protectowire products?(Required)

Who is your target market, and what is your promotional plan?(Required)

What information do you need from Protectowire to assist sales?

Projected Annual Protectowire Sales

Year 1 ($)(Required)

Year 2 ($)(Required)

Year 3 ($)(Required)

Credit References

Three trade or credit references

Reference 1 Name(Required)

Company(Required)

Phone(Required)

Email(Required)

Reference 2 Name(Required)

Company(Required)

Phone(Required)

Email(Required)

Reference 3 Name(Required)

Company(Required)

Phone(Required)

Email(Required)

Required Documents

Resale Certificate(Required)

State resale/tax exemption certificate

Max. file size: 256 MB.

Proof of Insurance(Required)

Commercial Liability - min. $1,000,000

Max. file size: 256 MB.

Additional Supporting Documents

W-9, references, capability statements, brochures — multiple files accepted

Drop files here or

Max. file size: 256 MB, Max. files: 6.

Business Contact Information

Contact Information

Company Background

Additional Details

Projected Annual Protectowire Sales

Credit References

Required Documents

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