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Grancrete, Inc.

Application for Distributorship Consideration

* indicates a required field.
*Geographical Area/Population:

I. Company Information
*Legal Name:
*Address:
 
*City: *State: *Zip:
*Telephone:
*Fax:
*Email:
*Principal Contact:
*Principal Contact Title:
*Year in Business:
Previous Names For This Business and businesses operated by any principal of this company within the last five (5) years:

II. Description of Company
*Legal form of Organization:
Other:
If a corporation, where is the incorporation?:
EVNI:
Name of President:
DOB of President:
ID # President:
Identify all Principal Operating Officers of your Organization
Vice President:
Vice President:
Vice President:
Sales Director:
Marketing/Advertising Director:
Chief Financial Officer:
Use the box below to list any other owners and partners:

III. Sales and Marketing
Under what structure will you incorporate Grancrete™ products (select one):
New division/department of an existing company
New, standalone company
Joint venture with existing company
New product line in an existing product line
Please provide a brief description of your selection:
How do you forsee incorporating Grancrete™ products infor your business (select all that apply):
As a part of a service you provide (i.e. construction of buildings using Grancrete™)
As a part of a finished product you produce
As a raw material sold to others
What voume of product usage do you forsee:
tons in the first 6 months
tons in months 7 - 12
tons in Year 2
tons in Year 3

IV. Other Information
*Have there been any voluntary or involuntary bankruptcies of the companies listed in Section I (A) and (G):
Yes: If so, please fax the details to us after completing this form.
*Have any claims been filed against the companies listed in Section I (A) and (G) for Trademark, Copyright or Patent infringements or for product liability:
Yes: If so, please fax the details to us after completing this form.
*Have any of the companies listed in Section I (A) and (G) been subject to proceedings before any National Trade Agency:
Yes: If so, please fax the details to us after completing this form.

V. Credit Application
*Name (as registered with the dept of taxation):
*Mailing Address:
 
*City: *State: *Zip:
Physical Address(if different):
 
City: State: Zip:
Telephone:
Fax:
Are you Rated in Dun & Bradstreet?:
Yes
No
Under what name?:

Tax ID#

Year Business Established:
Under Present Management:
Number of Employees:
Gross Annual Sales:
Estimated Net Worth:
Has the business ever been in receivership or declared bankruptcy during the last 7 years??:
Yes
No

Ownership
Corporation
Partnership
Proprieter
President, Partner or Owner:
Residence Address:
Home Phone: SSN#: $ Ownership:
Vice President, Partner or Owner:
Residence Address:
Home Phone: SSN#: $ Ownership:

Trade References
Supplier:
Address(Street or P.O. Box):
City: State: Zip:
Telephone:
Supplier:
Address(Street or P.O. Box):
City: State: Zip:
Telephone:
Supplier:
Address(Street or P.O. Box):
City: State: Zip:
Telephone:

Bank Accounts
Bank:
Address(Street or P.O. Box):
Banker or Contact:
Telephone:
Checking Account #:
Loan Account #: