Company Name: (*)

Address Line 1: (*)

Address Line 2:

City/State/Zip: (*)

Phone: (*)

Fax:

Contact Person: (*)

Contact Person Email: (*)

Web Site URL:

Years In Business: (*)

Federal Tax Identification Number:

Dunn and Bradstreet Number (DUNS):

Remittance Name: (*)

Address: (*)

City, State, ZIP: (*)

Contact Person: (*)

Payment Terms/Percentage Days/Net: (*)

What product(s) do you wish to offer?: (*)

Require special handling?: (*)

What are the methods of distribution?: (*)

Has your company done business with Tetco before? What Year?:(*)

Liability Insurance Provider (Amount and Expiration Date): (*)

Current Geographic Areas Served: (*)

Specific cost of product(s): (*)

What added value does your product(s) have over competition?: (*)

Targeted Customer Base: (*)

Marketing Plan: (*)

Ability to private label?: (*)

Disposition method for damaged, outdated, obsolete or discontinued merchandise: (*)