Company Name

Your Name

Mailing Address

City State

Zip Code

Shipping Address

City State

Zip Code

Phone Number

Fax Number

Your E-mail Address

Business Type is Corporation Partnership Sole Proprietor

Number of Salesmen

Equipment Brands Distributed

Presently Purchasing Chemicals From

Do you want Private Label? Yes No

Do you mix any of your own chemicals? Yes No

Your Geographic Area of Coverage by County or Parish

I would like help in: (choose all that apply)

Sales Training Product Knowledge Regulatory Issues Waste Management

Your Facility Information

Do you use a computer in your operation? yes No

Do you have a tractor-trailer freight dock? Yes No

Can you be served by a 53' trailer? Yes No If not, how long?

Do you have a fork lift? Yes No

Do you have pallet racks? Yes No

Would you be willing to attend training in Gadsden, AL? Yes No

What could Etowah Chemical do to make your distributorship more profitable?