Pre-Qualifying Form

Legal Company Name:*

Federal Tax Identification Number:

Years in Business:

Other Names or DBA Name:

Website:*

Billing address:*

SHIPPING ADDRESS IF DIFFERENT FROM ABOVE:

Email:

Cell:*

Work Number:

Fax Number:

Description of Company’s business activity:

Why do you want to sell Natural Spas?

Main Contact Name and Title:

Accts Payable Contact Name:

Accts Payable Email:

Authorized representative Name:

Authorized Signature:

Reset

Date:

Check all that apply:

We plan on ordering project by project:

We plan on keeping stock:

We are interested in having a display in our storefront/showroom:

We are interested in taking an installation class:

We have a storefront/showroom:

We supply our own equipment:

If interested in pool & garden products, please visit universalrocks.com