New Distributor Preliminary Application

Notice: By submitting this application you are requesting to become an authorized Lafferty Equipment reseller and you authorize us to gather information about your company,
as indicated below. Please fill in all * required fields.
If you cannot complete the application now, or if you wish to submit the form by fax,
click here for PDF version to fill out then print and fax.

* Company Name:

* Full Name:

* Title:

* Phone:

Alternate Phone:

* Fax:

* E-mail:

Website:

Billing Address

* Billing Address:

Address Line 2:

* City:

* State/Province:

* Zip/Postal Code:

* Country:


Shipping Information (if different from billing)
Please note: We cannot ship to P.O. Boxes; Ship address must be physical address.

Shipping Address:

Address Line 2:

City:

State/Province:

Zip/Postal Code:

Country:


Prequalification Questions

* How frequently will you have a need for this or related product?

* Are you a chemical company or chemical reseller?	Yes	No

* Number of locations?

* Number of outside sales reps?

* Do you sell other chemical application equipment?	Yes	No

If so, what brands?

* Do you plan to offer installation and technical support?	Yes	No


Agreement
* I verify that I am legally able to make contracting and purchasing decisions for my company. By submitting this form I understand that a Lafferty Equipment representative will contact me to verify this and other information. I understand that submission of this form and a completed phone interview does not guarantee my/our acceptance into the Lafferty Equipment Distributor Program. If I am accepted as a Lafferty Distributor, I agree to be placed on the Lafferty Equipment distribution list to receive Lafferty marketing literature, and other reseller communications via mail, delivery, e-mail, fax, or phone.

*I agree

* Initials

* Indicates Response Required

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Lafferty Equipment Manufacturing, Inc. • 5614 Oak Grove Road, N. Little Rock, AR 72118 • 501-851-2820