Distributor Application
Customer Information Fields with an * are required.
First Name*:
Last Name*:
Address:
Address 2:
City:
State:
Zip Code:
Home Phone*: ( ) -
Fax: ( ) -
Cell: ( ) -
E-mail Address*:
Company Information
Do you currently own your own business?
Company Name:
Business Address:
Address 2:
City:
State:
Zip Code:
Business Phone: ( ) - Ext
Direct Line: ( ) - Ext
Work Fax: ( ) -
Business Hours:
What products does your company currently sell?:
Website:
Distributor Information
What type of service would you provide?*:
The Mini-Max Sales:
Yes No
Residential:
Sales Service Both
Commercial:
Sales Service Both
Do you currently rent carpet or upholstery cleaning equipment?*: Yes No
You would be able to work:
 
How did you hear about Thermax?*:
Comments: