Dr. Z's "Personal Portable Oxygen/O2 Bar"

Dealer Application Form

   
  Type *
Distributor
Affiliate
Dealer
Independent Sales Rep 		   
  Contact Name *
Dr.
Mrs.
Mr.
    
  First Name /Last Name *
    
  Company *
    
  Street Address, City, State, Zip, Country *
    
  Phone *
    
  Fax *
    
  Alternate Phone
    
  Email Address *
    
  Website URL
    
  Business Type *
    
  Year Founded *
    
  # of Employees *
    
  Current Products in Trade *
    
  Average Sales Volume Per Year for Last 3 Years *
    
  Distribution/Sales Territory Interested In *
    
  Prospective Market- i.e. chiropractic, acupuncture, naturopath, massage therapy, physical therapy, etc. *
    
  EIN#/SS# *
    
  Specification Requirements *
RoHS Approval Required (refers to 230V ONLY)
CE Approval Required (refers to 230V ONLY)
115V (UL-Underwriters Laboratories/CSA-Canadian Standard
230V (Plug Type___________ For Office Use Only)