DISTRIBUTORSHIP APPLICATION FORM

GENERAL INFORMATION Please fill in all blanks by typing or write legibly.

Company Name: ________________________________ TIN #:

___________________
Form of Business Ownership: Sole Proprietor Partnership
Corporation
Owner Name:
___________________________________________________________
(If Sole Proprietor) Last Name First Name Middle

Address:
_______________________________________________________________
#/Unit/Bldg. Street Brgy. City
State/Province

Contact Person: ________________ Position: ___________ Contact #:

_____________
Mobile #: _______________ Email: _________________ Website:
________________
Nature of Business: ________________________ Years of Business:
______________
Branch Office/Store: ______________________________ Tel No:

AFFILIATES Principal Officers

_______________
Accounting Manager: __________________ ________________
_________________
Complete Name Contact Number
Signature
Purchasing Officer: __________________ _______________
__________________
Complete Name Contact Number
Signature

SUPPLIER
________________ ________________ ____________ _____________
________
Supplier Name Address Contact # Contact
Person Terms
________________ ________________ ____________ _____________
________
Supplier Name Address Contact # Contact
Person Terms
________________ ________________ ____________ _____________
________
Supplier Name Address Contact # Contact
Person Terms

I Hereby Certify that all the Information Herein Stated Above are True and Correct

__________________________ ______________________
PRINTED NAME AND SIGNATURE DATE

Please submit the following documents together with this application form.

1. Articles of Incorporation and By-Law 5. DTI Registration (Business Name) for sole proprietorship
2. Business Permit/Mayor’s Permit 6. Authorization to Verify Bank History
3. Financial Statements for the last 2 years 7. Bank Statement for the last 3 months
4. Company Profile 8. 2 Government Valid ID’s of the Owner with photo
with
 BANK AUTHORIZATION FORM
This is to authorize _______________________________________________
or it’s Representative to verify my accounts to wit:
BANK BRANCH ACCOUNT NAME ACCOUNT NUMBER

This authorization is being issued in connection with my application

for my distributorship application with the above mentioned
company.

I hereby affix my signature this _________________day of

____________20____.

Authorized Signatory
______________________
Signature over Printed Name
Bank’s Remarks:
1. Number of year as client.
2. Types of Account/s maintained
3. Record of the Account
a. It is properly handled?
b. Any history of returned cheques?
c. Is it an active account?
4. Other comments.

Name of Verifier
_______________________
Signature over Printed Name