Distributor Application
Rental Location Distributor / Dealer Application
Company Information Fields with an * are required.
First Name*:
Last Name*:
Are you currently business owner? Yes No
Do you have an active business license? Yes No
Do you have an active Tax ID #? Yes No
Company Name:
Address:
Suite / Apt. No.:
City:
State:
Zip Code:
Business Phone: ( ) - Ext
Best # to reach you: ( ) - Ext
Fax: ( ) -
E-mail Address*:
Website:
Business Hours:
Nature of Business Location:
Products your company currently sells:
You plan to distribute Thermax products:
Products and Services
Please specify products and services you will offer.
Thermax Rental Center
Are you interested in having a Rental Center
in your own store?*:
Yes No
Will provide service for your Rental Center(s)?*: Yes No
Are you interested in setting up multiple Rental
Centers in your area?*:
Yes No
Are you interested in marketing our
CP3-Heated Extractor (hose & wand unit)?*:
Yes No
Are you interested in marketing our
Self-Contained Extractor (all-in-one unit)?*:
Yes No
What is your realistic goal for the # of rental locations you will setup?:
How do you plan on marketing this particular product line?:
Who will you be approaching as your potential customers?:
 
Additional Information
Please list the zip code/s in which plan to market and/or want protection in:
How did you hear about Thermax*:
Comments:
Somone from our corporate office will contact you within 1 to 2 business days of you submitting this application.