Become an Authorized Distributor – Kwickfix

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Name of the company *

Office Address *

City

State/Province

ZIP / Postal Code

CountrySelect country

Office Landline no. *

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Mobile no. *

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Fax no.

Email Address *

Corporate Status *Select one

Year Of Establishment *

Name of proprietor/Partners/Directors *

Residential Address of Proprietor/Partner/Directors

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

CountrySelect country

Mobile no. of Proprietor/Partners/Directors

Godown/Warehouse *

Address

City

State/Province

ZIP / Postal Code

CountrySelect country

Godown Landline No. *

Size/Area (sqft) *

Owned/Rental *OwnedRental

Products Currently Handled *

Approximate Sales Volume *

Total Number of Staff *

Number of Sales Persons *

Existing Distribution Network: Brands/Company *

Number of Retail Counters/Outlets catered *

Geographical Area of Distribution *

(Please mention all Pin codes of areas catered by you)

Connections/Enlistment with Govt. Dept/Public Bodies/NGO *YesNo

If Yes please provide details

Which of the Kwickfix products are you interested in? *

GST Registration Number *

PAN Number *

Bank Details *

Include : Bank Name, Branch Name, Bank Account Number

Consent *

I/We declare that the above information are true and correct to the best of my/our knowledge and I/We am authorize to sign this declaration for consideration of distributorship with your Company Upload signature with Seal/Stamp of Firm Please upload following Attested documents along with Application Form

1. Xerox of GST Certificate *

No file chosen

2. Xerox of PAN Card *

No file chosen

3. Photo Id proof of Proprietor/Partners/Directors *

No file chosen

4. Residential Proof of Proprietor/Partners/Directors *

No file chosen

5. Cancel Cheque or Xerox copy of Cheque *

No file chosen

6. E-sign *

No file chosen

Name *

Date *

Name

Phone No.

Email ID

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