Become a PCA Distributor

APPLICATION FOR DISTRIBUTORSHIP

I/We the undersigned :
APPLICANT
Company Legal Name :
Doing Business as :
Address :
City :
Province :
Postal Code :
Telephone :
Fax :
E-mail :
ASSOCIATIONS - Member #
OTHER INFORMATION
Legal Name :
CONTACT
Payable :
Telephone - 1 :
Fax - 1 :

Invoice mailed :
Purchase order required - Yes :

Desired credit :
$
Purchasing :
Telephone - 2 :
Fax - 2 :
E-mail :
GENERAL INFORMATION
Type of ownership:
Type of business :
Years in business, under present ownership :
Annual sales :
Estimated monthly purchases :
If less than 3 years, other similar business :
Principal’s Name - 1 :
Title :
S.S.N. * :
Date of Birth :
Address :
City :
State :
Residential Telephone :
Principal’s Name - 2 :
Title :
S.S.N. * :
Date of Birth :
Address :
City :
State :
Residential Telephone :
Premises:
If Rent, Name of Landlord :
*S.S.N. Optional
BANK
Name :
Account No. :
City :
Fax :
Address :
Telephone :
E-mail :
CREDIT REFERENCES
Company Name - 1 :
Contact :
Telephone :
Fax :
E-mail :
Company Name - 2 :
Contact :
Telephone :
Fax :
E-mail :
Company Name - 3 :
Contact :
Telephone :
Fax :
E-mail :
Company Name - 4 :
Contact :
Telephone :
Fax :
E-mail :
Company Name - 5 :
Contact :
Telephone :
Fax :
E-mail :
CREDIT CARD AUTHORIZATION
Credit Card # :
Exp. Date (MM / YY):
*By signing this section, you authorize Publi Calen-Art Ltd to apply purchases to the credit card