Distributor Application Please fill out the following fields accurately with your information

Company
Designation
Full Name	Mr. Mrs. Miss. Ms. Prof. Dr. Sir.
Address 1
Address 2
City
State
Code / Zip
Country	Select OneAfghanistan Albania Algeria Angola Argentina Armenia ASEAN Australia Austria Azerbaijan Bahmas Bahrain Bangladesh Belgium Belorussia Benin Bermuda Bhutan Bolivia Botswana Brazil Brunei Bulgaria Burkina Faso Cambodia Cameroon Canada Chad Chile China Columbia Congo Costa Rica Croatia Cuba Cyprus Czech Denmark Dominican Rep. East Africa Ecuador Egypt Estibua Estonia Ethiopia Euro.Comm.Market Ex-ussr Less Ru Fiji Finland France French Guiana Gabon Germany Ghana Greece Guatemala Gulf Guyana Haiti Holland Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kirgizia Korea Kuwait Kyrgyzstan Laos Latin America Latvia Lebanon Liberia Libya Lithuania Lote D' Ivore Luxemberg Macau Madagascar Malawi Malaysia Maldives Mali Malta Mangolia Mauritania Mauritius Mexico Middle East Moldavia Morocco Mozambique Muscat Myanmar Namibia Nepal Netherland New Zealand Nicaragua Niger Nigeria North Africa North Korea Norway Not Available Oman Pakistan Palestine Panama Paraguay Peru Philippines Poland Portugal Qatar Rio Muni Romania Russia SAARC Salvador Saudi Arabia Senegal Seychells Sierre Leone Singapore Slovakia Slovenia Somalia SA South Africa SEA South East Asia South Korea Spain Sri Lanka Sudan Surinam Sweden Switzerland Syria Taiwan Tajkistan Tanzania Tatarstan Thailand Togo Trinidad&Tobago Tunisia Turkey Turkmenistan U.A.E. U.K. U.S. Uganda Ukraine Uruguay Uzbekistan Venezuela Vietnam Yemen Yugoslavia Zaire Zambia Zimbabwe
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
HomePage

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 name of ticked above
Which distributor status are you applying for?	Independent Distributor  Exclusive Distributor
* Please note Country and State geographical regions will only be considered by persons or companies able to effectively cover and handle the total region area that is applied for

Please give a brief description of yourself or your company and any other information relevant to this application