Retail / Distributor Customer Application 1Contact Information2Business Information3Billing & Shipping4Credit References Please complete each step below by filling in all required fields before continuing to the next step.The Save and Continue button will create a link for continuing the form at a later date. You will be presented with a custom link to the current state of your form submission, with the option of sending the link to your email. Links created will be accessible for 30 days.Company Name(Required)Website(Required) Contact Name(Required)Buyer(Required)Company Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code United StatesCanada Country Email(Required) FaxReferral SourceDid someone refer you to us? Please enter their name here. Business Type(Required)Select…Big BoxBuying GroupDealerDistributorYears In Business(Required)Business License #(Required)Please provide a copy of your current business license.(Required) Drop files here or Select files Max. file size: 32 MB, Max. files: 1. Number Of Stores(Required)Number Of Employees(Required)Are you a member of any buying groups?(Required)Please list each buying group you are a member of on a new line or type none if not applicable.Which industry trade shows do you attend?(Required)Please list each trade show on a new line or type none if not applicable.Do you take advantage of early booking Discounts?(Required) Yes No Dealers – Who are your three main suppliers?(Required) Add RemoveClick the PLUS icon to the right to add more as needed.Distributors – Please list three references.(Required) Add RemoveClick the PLUS icon to the right to add more as needed.How many traveling sales reps are employed?(Required)How many phone reps are employed?(Required) Sales Associate(Required)Business Type(Required) Sole Proprietorship Partnership Corporation Other Bill to Name(Required)Billing Address(Required) Same as Company Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code United StatesCanada Country Billing Phone(Required)Billing FaxBilling Email(Required) Ship to Name(Required)Shipping Address(Required) Same as Billing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code United StatesCanada Country Shipping Phone(Required)Shipping FaxShipping Email(Required) Owner or Principal(Required)Business Established(Required) MM slash DD slash YYYY Store Contact 1(Required)Store Contact 2State Sales Tax #(Required)State Sales Tax # (attach copy)(Required) Drop files here or Select files Max. file size: 32 MB, Max. files: 1. Reference 1Name(Required)Contact(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code United StatesCanada Country Phone(Required)FaxEmail(Required) Reference 2Name(Required)Contact(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code United StatesCanada Country Phone(Required)FaxEmail(Required) Reference 3Name(Required)Contact(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code United StatesCanada Country Phone(Required)FaxEmail(Required) Signature(Required)Consent(Required) I acknowledge that Norsk, Inc. reserves the right to run credit checks by way of references provided as well as major business credit reporting agencies at any time during the business relationship. This may have an impact on the allowable credit granted to my account, if any is granted. Δ
