Distributor Application

We invite you to apply for a WP Fail-Safe LLC™ distributorship.

Applications will be reviewed and evaluated based on geographical location, number of store fronts, potential sales volume and a number of other factors. Not all applications will be accepted. By submitting the following confidential information, you are granting WP Fail-Safe LLC permission to perform a credit inquiry regarding your company.

Please fill in the following information prior to submitting this application.

	*** Indicates Required Field**
* Company Legal Name:
DBA (if Applicable):
* Country:
* Billing Address:

* City:
* State / Province:
* Zip Code:
* Phone:
Fax:
* Email:
* FEIN #:
Dunn & Bradstreet #:
* Business Type:
* Years in Business:
* Number of Locations:

Contact for Vendor Relations or Product Sourcing:
* Contact Name:
* Title:
* Email:
* Phone:

If Principal(s) location is different from the address above, please click here:
* Principal's Name:
* Country:
* Address:

* City:
* State / Province:
* Zip Code:
* Phone:
Fax:
* Email:

Financial Information:
* Sales Volume for 2008:
* Sales Volume for 2009:

Trade Reference 1:
Company Name:
Contact:
Phone:
Email:
Trade Reference 2:
Company Name:
Contact:
Phone:
Email:

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