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Dealer Registration

Please first indicate whether you are registering a new user login account for an existing dealer or a new dealer company. Then enter the following information about your company. Alconox will contact you within 10 days with a user name and password if approved. All new dealers must be prepared to place an initial order of 4 cases once approved. A minimum of one order per year must be placed thereafter to maintain the dealer discount.

   

Error

Items in red are required.


Company Information
Your Name:  
Title:  
Company Name:  
Address 1:  
Address 2:  
City:  
Region/State/Province:  
Postal/ZIP Code:  
Country:  
Phone:    ext:   
FAX:  
Email Address:  
Web:  
Year Established:  
Type of Business:  
Owner/President:  
EIN/SSN:  
Controller/Treasurer:  
Shipping Information
Recipient Name:  
Company Name:  
Address 1:  
Address 2:  
City:  
Region/State/Province:  
Postal/ZIP Code:  
Country:  
Phone:    ext:   
Special Instructions:  
Bank Information
Bank Name:  
Address 1:  
Address 2:  
City:  
Region/State/Province:  
Postal/ZIP Code:  
Country:  
Phone:    ext:   
FAX:  
Contact (Bank Officer):  
Account Numbers
Checking:  
Money Market:  
Acknowledge
Trade References (three required)
REFERENCE #1
Company Name:  
Company Email:  
Address 1:  
Address 2:  
City:  
Region/State/Province:  
Postal/ZIP Code:  
Country:  
Phone:    ext:   
FAX:  
REFERENCE #2
Company Name:  
Company Email:  
Address 1:  
Address 2:  
City:  
Region/State/Province:  
Postal/ZIP Code:  
Country:  
Phone:    ext:   
FAX:  
REFERENCE #3
Company Name:  
Company Email:  
Address 1:  
Address 2:  
City:  
Region/State/Province:  
Postal/ZIP Code:  
Country:  
Phone:    ext:   
FAX:  
Financial Structure
Is your company a Corporation?  
If so, is it a Public or Private Corporation?  
What Exchange is your Corporation listed under? Exchange:  
Symbol:  
Is your company a Subsidiary, Partnership, or Sole Proprietorship?  
What is the intended purpose of purchased cleaners?
Does your company intend to purchase cleaners for:  
If for resale, to what markets? (select all that apply)
















   
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