Panalt
Distributor Application
Please fill out the following fields accurately with your information
This is a preliminary application and contractually binds you and us in no way whatsoever

Company
Designation
Full Name
Address 1
Address 2
City
State
Code / Zip
Country
If your application is successful the following area code and phone number would be the number displayed for the general public to contact you as a distributor for their area
Telephone Area Code
Number
Fax Area Code
Number
Email
Home Page
Do you have previous sales experience? Yes No
How do you intend to resell our products Internet
Home Sales
Retail (Your own store)
Commercially (To retail outlets)
Which size geographical area are you applying for? Neighbour Hood (Zip area)
City
State*
County*
Please specify geographical area named above
Which distributor status are you applying for? Independent Distributor 
Exclusive Distributor
* Please note: Country and State geographical regions will only be considered if the persons or businesses is fully able to effectively maintain the total region or area that is applied for!
Please give a brief description of yourself or your company and any other information you feel may be relevant to this application in the box below