NEW CUSTOMER INFORMATION FORM

The following information will help us to become acquainted with your organization. All information will be held in strictest confidence.
(Note : All fields marked as * are compulsory)

Company Name (Please use full legal name.)	*
Address
Street 1	*
Street 2
City	*
Prov./State	*
Country	*
Postal Code	*
Phone #	*
Fax #
Cell #
Email
Web Site
Mailing Address
Street 1
Street 2
City
Prov./State
Country
Postal Code

Branch Locations:

Branch Name Address Contact Person Telephone #

Key Business Contacts
General Management
Sales
Accounting
Type of Business ( Please check   )
Corporation Partnership Sole Partnership
Type of Activity ( Please check   )
Manufacturer Distributor / Wholeseller Retailer
If other, please specify
In Busineess Since
Bank Reference
Bank Name
Address
City
State
Phone #
Fax #
Contact Person
Title
E Mail
Sales History (USD Equivalent)
1999 2000 2001 2002 2003
Geographic Territory Represented
Market Areas Served ( Please check   )
Agriculture Janitorial Pest Control Household Other
Products or Services presently marketed

What other suppliers do you represent?
Company	Product Type	% of total sales
Do you sell product similar to Air Guard?
YES    NO
If yes complete the following
Company	Product Type	% of total sales
You are interested in becoming
Distributor / Wholeseller	Retailer	End User
What products are you most interested in: (Check as many as apply)
Metered Aerosol - BVT Metered Aerosol - CSA Odour Control Products	Insecticide Products Aromatherapy Products Fans and Gels
Additional Information we should know about your company