GENERAL INFORMATION

Business Trade Name (DBA)

Business Legal Name (as it appears on business license)

Business Street Address

City, State, Zip

Business Phone

FAX

E-mail address

Officer/Owner Name / Title

Secondary Contact Name / Title

DESCRIPTION OF BUSINESS

This company is a (Check one): Sole Proprietorship Partnership Corporation

Are You a franchise dealer for a major manufacturer? Yes No

Business Operates From:

Own Building Office Building Home Other Approximate Sq. Ft:

Current Industry Membership (check all that apply):

CIC ASA ISA AAIA PBES SGIA NPCA ACA
Other

Primary Products:

DuPont 3-M PPG SW BASF
Other

Number of Branches/outlets operated/managed by you:

Please note: Your information is held in strict confidence & is never shared with third parties.