Micron Engineering Corporation

Distribution

Distributor / Dealer Application form

Basic Information
Name Of The Applicant :	*
Application Requested By :
Company Name :	*
City :	*
State / Province :	*
Country :	*
Zip Code :	*
Telephone (enter country/city code, if applicable):	*
Fax :
E-mail :	*
Website :
Contact Information

Shipping Address

Marketing Address

Accounts Address

Name :

Address :

City :

State / Province :

Country :

Zip Code :

Telephone:

Fax :

E-mail :

Local Sales Tax Number (Indian Distributor/Dealer) :

Central Sales Tax Number (Indian Distributor/Dealer) :

PAN Identification Number (Indian Distributor/Dealer) :

VAT Number (Overseas / Indian Distributor/Dealer) :

Year Established :

Business Status :

Nature Of Business :

Total Number Of Employees :

Products Details

Products Handled	Description	Manufactured By	Arrangement *

Note: * Please mention the nature of arrangement such as Exclusive, Non-exclusive, Agent, Importer, Dealer, Distributor, Representative, Liasioning agent, etc...

Business Details

List of Existing Customers/Sector:




List of Potential Customers/Sector:

Annual Turnover :

Products Category :

Accessories

Couplers & Pneumatics

Potential Volume

Existing Volume of Similar Products :

Required Volume of Our Products :

Investment Planning

Existing Investment on Similar Products :

Planned Investment on Our Products :

Bank References

Bank Name :

Address :

A/c No :

Fax :

E-mail :

Aim

Any other details you would like to highlight?