Date:

VENDOR: (include trade names)

TYPE OF MERCHANDISE: (please describe)

BEST SELLING ITEMS:

NAME(S) OF YOUR MAIN COMPETITORS

BEST TYPE OF RETAILERS TO BE TARGETED:

Contact Information

Principal' )

Home Ph/Fax

s /President:

Home Ph/Fax

Sales Manager:

Customer Service contact:

Credit Contact

(Check One)

SOLE PROP

Corp.

Partnership

State

Mailing address-

City

Zip

FOB / shipping address-

State

City

Zip

800#

800 FAX#

E-Mail

Alternate phone #

Web Site internet address

%

How long in business?

COMMISSION Rates:

*Total US Sales Volume (1999)$

You are looking for coverage in what states?

*Total Sales Volume (1999) ABOVE STATES $

Yes

No

Will you send us an account list for our territory?:

Yes

No

Will You send us salesman samples at no charge

Will You drop ship our territory reps samples/sales materials?-

Yes

No

Your Live Cust Service Hours of Operation?:

True

False

Mostly answering machine

%

What percent of orders received do you ship

Typical Ship Lead Time:

Requested OPENING ORDER: $

Requested REORDER: $

You pay commissions on (check one)

UPON RECEIPT OF PAYMENT FROM CUSTOMER

MONTHLY AFTER INVOICING

Will You Send us Shipping/Invoice Confirmation Copies:

No

Yes, Monthly Other

What classes of trade do you want us to cover:

ALL CLASS OF TRADE

OR SPECIFY:

HOUSE ACCOUNTS IN OUR AREA:

NONE

OR SPECIFY HOUSE ACCTS:

Indicate Terms You Accept:

N30

COD

MC

VISA

AMEX

DISC

NEW ACCOUNT POLICY:

Freight policy:

Volume Discount or Allowances & commission rates:

Yes

No

Is product U.P.C coded?:

Yes

No

Do You have a current catalog?:

Any other comments:

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

References

PREVIOUS SALES FIRM (in New England)

PREVIOUS SALES FIRM (in New York, NJ)

OTHER SALES AGENCIES THAT ARE CURRENTLY REPRESENTING YOU: (LIST 3 PLEASE)

TELEPHONE

PRINCIPAL

PRINCIPAL

PRINCIPAL

TELEPHONE

TELEPHONE