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Company Name*
Tax ID#*
Retail License#
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
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Federal ID
Email*
Website*
Do you have a showroom?
Do you feel like a showroom display would help you sell our product?
How many sales/designers on staff?
Sales/Designers
Sales/Designer Name Sales/Designer Email Sales/Designer Email Sales/Designer Email

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How did you hear about Kessick?*
Please specify.*
Name of Manufacturer's Rep
Primary Interest
What design software do you use? Chief Architect, SketchUp, DWG files available upon request
Define your geographical territory*
What product lines do you sell?
Tell us about your company and why you think Kessick is a good fit*
Trade References*
Company Name Address Telephone Fax
By signing this agreement, you are acknowledging you understand Kessick’s Design Fee and Payment Policies and that Kessick Wine Storage Systems’ catalog, photos, pricing and order form are the property of Kessick and are not to be copied or distributed without permission.
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Authorized Signature*

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Company Name	Address	Telephone	Fax

Authorized Wine Cellar Dealer Network and Trade Application

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