Lifeboat Distribution - Reseller Application Form

Customer Information

Company Legal Name: *

Date of Business Established:

DBA:

Country: *

Address 1: *

Address 2:

City: *

State: *

Zip / Postal Code: *

Telephone #: *

Other Information:

Company Website:

Number of Employees: *

Number of Sales Employees: *

Number of Service Employees: *

How did you hear about us?

What product lines from Lifeboat brought you to us?

Tax Information

For United States For Canada For Europe

Federal Tax ID: *

Yes No

PST #: *

Contact Information

Main Sales Contact *

First Name: *

Last Name: *

Job Title: *

Telephone #: *

Mobile #:

Email: *

Subscribe to Newsletter?

Yes No

Main Service Contact

First Name:

Last Name:

Job Title:

Telephone #:

Mobile #:

Email:

Subscribe to Newsletter?

Yes No

Main Accounting Contact *

First Name: *

Last Name: *

Job Title: *

Telephone #: *

Mobile #:

Email: *

Subscribe to Newsletter?

Yes No

Financial Information

Primary Contact

First Name:

Last Name:

Job Title:

Telephone #:

Mobile #:

Email:

Secondary Contact

First Name:

Last Name:

Job Title:

Telephone #:

Mobile #:

Email:

Additional Information

Company Type:

Payment Type: *

Monthly credit amount you would like to receive: *

Does your company use flooring?

Yes No

Flooring Company:

Dun & Bradstreet #:

Company Type Information

Company type: *

First Name:

Last Name:

Job Title:

% of Company Ownership:

Upload Financials

Financials (Optional):

Browse

Drag & Drop Financials Here

Trades / Bank Info. (Optional):

Browse

Drag & Drop Trades / Bank Information Here

Application Authorization and Submission

First Name: *

Last Name: *

Job Title: *

* By agreeing to this reseller application form, you are confirming that you have approval authorization at your company and will be bound by the Lifeboat Distribution’s Reseller Terms & Conditions, which are available at: Lifeboat Distribution Terms & Conditions.