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*City : *State/Province :

*Zip/Postal Code : *Country :

*Phone No : *Fax :

*Email :

*Website :

*Type of Business :

*Ownership: *Sole Owner/Individual *Partnership *Corporation

*Skype Id :

*Vendors you currently do business with :

*Name of City (for dealership ) : *State :

Do you have a showroom/retail storefront? Yes :

If yes, what percentage of retail floor space would be allocated for COBRA products?
0-25% 25-50% 50-75% 75% or more

Do you currently or plan to do online business through Internet? Yes :

If yes, what percentage of your total sales would result from Internet sales?
0-25% 25-50% 50-75% 75% or more

I hereby state that the information contained herein is correct and not misleading, and agree to the terms described in the Dealer Agreement associated with this Application. I understand the above information is given in confidence for the sole purpose of requesting an account with SANTEC HYDROFLUID ENGINEERS ( COBRA )

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