Distributor Application Please Complete and Submit a Distributor Application to Become a Distributor of Timilon’s Products. Step 1 of 3 33% Your Name*Company Name*Company Address*Phone*FaxMobileEmail* Website* Company is:CorporationLLCSole ProprietorOtherIf Other, Please List Federal Tax ID# or SS#Years in Business*Please enter a value between 0 and 200.Years at Current LocationPlease enter a value between 0 and 200.Annual Sales Revenue for 2009Please enter a value greater than or equal to 0.Annual Sales Revenue for 2010Please enter a value greater than or equal to 0.Annual Sales Revenue for 2011Please enter a value greater than or equal to 0.Annual Sales Revenue for 2012Please enter a value greater than or equal to 0.Annual Sales Revenue for 2013Please enter a value greater than or equal to 0.Employees Are:Full TimePart TimeContractedHow many Full time employees?How Many Part Time Employees?How Many Contracted Employees?Representatives are:SalesCustomer ServiceOtherHow Many Sales Representatives?How Many Customer Service Representatives? How Many Other Representatives?Define Current Target MarketsTotal Number of Products for SaleList Top Selling Products*Product NameProduct DescriptionPercentage of Annual Revenues Do You Currently Represent Any Other “NANO” Type Products or Services?YesNoIf Yes, Please Define:Please ListContracted Supply AgreementsProductsDefine Distribution Methods Please State Reason(s) for interest in Timilon's Products and ServicesReferencesNameAddressPhone Number (Professional/Business) Minimum 3ReferencesNameAddressPhone Number (Credit) Minimum 3BankNameBranchPhone 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* Δ