Distributor Application

Company Information

1. Company Name
2. Mailing Address
3. Shipping Address
4. Office Phone Number
5. 2nd Phone Number
6. Fax Number
7. E-Mail Address
8. Company Website
9. Date Business Started
10. Federal ID #
11. Sales Tax Exemption #
12. Business Type Corporation Partnership Sole Proprietorship Limited Liability Corporation S-Corporation

Contact Information

1. Main Contact Name
2. Main Contact Title
3. Main Contact Cell Phone #
4. Main Contact E-Mail Address
5. Office Manager
6. Office Manager E-Mail Address
7. Service Manager
8. Service Manager E-Mail Address

Sales Personnel

1. Sales Manager
2. Sales Manager E-Mail Address
3. Sales Manager Cell Phone #
4. Sales Person #1
5. Sales Person #1 E-Mail Address
6. Sales Person #1 Cell Phone #
7. Sales Person #1 Office Location
8. Sales Person #1 Territory Covered
9. Sales Person #2
10. Sales Person #2 E-Mail Address
11. Sales Person #2 Cell Phone #
12. Sales Person #2 Office Location
13. Sales Person #2 Territory Covered
14. Sales Person #3
15. Sales Person #3 E-Mail Address
16. Sales Person #3 Cell Phone #
17. Sales Person #3 Office Location
18. Sales Person #3 Territory Covered
19. Sales Person #4
20. Sales Person #4 E-Mail Address
21. Sales Person #4 Cell Phone #
22. Sales Person #4 Office Location
23. Sales Person #4 Territory Covered

Business References

1. Company Name #1
2. Contact Name #1
3. Contact Name #1 Cell Phone #
4. Company Name #2
5. Contact Name #2
6. Contact Name #2 Cell Phone #
7. Company Name #3
8. Contact Name #3
9. Contact Name #3 Cell Phone #
10. Company Name #4
11. Contact Name #4
12. Contact Name #4 Cell Phone #

Authorization

1. Name of Person Completing Application

Validation

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ICU-Remotely, LLC    |    6740 Allisonville Road    |    Indianapolis, IN 46220    |    Phone/Fax: (317) 863-5656