Biostim Distributor Questionnaire

BioStim® Distributor Questionnaire


	Fields marked with * are required
Your Name *
Title *
Company Name *
Company Address *
Company Address 2
City *
State/Province *		* Zip Code/Postal Code
Country
Phone *
Fax
Email *
Website Address
How did you hear about BioStim?

Will you be the primary contact between BioStim and your company? YES NO If NO, please indicate: Name Title
Are you an owner or manager of the company? YES NO
How long has the company been in business?
What type of business is the company?
How many employees does the company currently employ?
Who in your company is authorized to sign an agreement/contract?
What area does the company distribute to:
Which products are you interested in distributing? MicroDrip Drain Line – cartridges (used with MicroDrip Dispenser) MicroDrip Hygiene – cartridges (used with MicroDrip Dispenser) BioPlug L – for high flow lift stations (used with BioFloater) BioPlug CS – for low flow lift stations and sewer lines BioPill – for indoor grease interceptors Super Aug Pill – for outdoor grease traps Drain Line BioFoam – 32 oz concentrate Septic Saver Oozi Foamer with wand (used with Drain Line BioFoam) T-Lift – for lifting manhole covers
How many units do you anticipate distributing? Per month Per year
How do you plan on marketing BioStim products?

Optional –References will only be checked if a Distributor Agreement is drafted for signature. Any information given is confidential and will not be shared. Please list vendors and bank references
Vendor Name Address Vendor Name Address
Bank Name: Acct # : Address:
Bank Name: Acct #: Address:

Optional –References will only be checked if a Distributor Agreement is drafted for signature. Any information given is confidential and will not be shared. Please list 2 customer references: Customer How Long? Customer How Long?
By completing this questionnaire you give BioStim, LLC authorization to contact the references listed only after a Distributor Agreement has been drafted for signature. Any information given is confidential and will not be shared. Thank you for completing the Distributor questionnaire, a representative of BioStim will be contacting you.