Online Distributor Application - Timilon Corporation

How Many Other Representatives?
Define Current Target Markets
Total Number of Products for Sale
List Top Selling Products*
Product Name Product Description Percentage of Annual Revenues
Do You Currently Represent Any Other “NANO” Type Products or Services?
- Yes
- No
If Yes, Please Define:
Please List
Contracted Supply Agreements Products Define Distribution Methods
Please State Reason(s) for interest in Timilon's Products and Services
References
Name Address Phone Number

(Professional/Business) Minimum 3
References
Name Address Phone Number

(Credit) Minimum 3
Bank
Name Branch Phone Number
By checking the box below , I attest that I am authorized to make application and provide the information contained herein. I further authorize Timilon to contact any of the References provided as part of their due diligence.*
- I agree.
Date*

Distributor Application