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Distributor Application Form
All interested distributors are to fill this form and send to us
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* Indicates required question
Client Name:
*
Your answer
Address:
*
Your answer
Phone:
*
Your answer
Email:
*
Your answer
Company website:
Your answer
Date of Establishment:
MM
/
DD
/
YYYY
Principal contact name:
*
Your answer
Principal contact’s email:
*
Your answer
Nature of Firm:
Partnership
Private Ltd
Clear selection
Type of Business:
Retailer
Wholesaler
Import/Export
Manufacturer
Clear selection
Other (specify)
Your answer
Products/services you currently offer:
Your answer
Number of years in business:
Your answer
Number of locations:
Your answer
Number of employees in sales:
Your answer
Number of employees in technical service:
Your answer
Yearly revenue:
*
N1m to N10m
N10.1m to 20m
Above 20m
Products and Service you are interested in distributing or Franchising:
*
19L Water (5 Gallon JAR)
Undersink Reverse Osmosis Systems
Reverse Osmosis System (from 1000LPH)
Reverse Osmosis Membrane
Fibre Glass Cylinders
Water Dispenser Machine
Water Treatment Services
Water Store
Water Bagging Machine (Sachet Machine)
Bottle Blower
Rinsing, Filling, Capping Line for Water Bottling
Your target market for distributing I-MACONI products (Local Government Area):
Your answer
Please tell us briefly how you plan to promote and sell products:
Your answer
How much volume do you plan to sell in the next 12 months?
Your answer
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