DISTRIBUTOR APPLICATION

Apply to Become an Earthrings USA Distributor

Complete the application below.

DISTRIBUTOR APPLICATION FORM

Please complete all sections. All information will be kept confidential.

1. COMPANY INFORMATION

Company Name: Year Established:

Business Address:

City: State: Zip Code: Country:

Website: Tax ID / EIN:

Primary Contact Name: Title / Position:

Email: Phone:

Alternate Contact Name: Title / Position:

Email: Phone:

3. EXPERIENCE & CAPABILITIES

Do you currently sell products into the industrial / electric motor repair or maintenance market?

Yes No

How many years of experience do you have in this industry?

Do you currently sell shaft grounding or bearing protection products?

Yes No

If yes, which brands?

Do you have a sales team?

Yes No

If yes, how many?

Do you have warehousing or distribution capabilities?

Yes No

List any key territories you currently serve:

4. INTEREST & COMMITMENT

Why are you interested in becoming an Earthrings Prime Distributor?

What territories are you interested in representing? (State(s) / Region)

Estimated Initial Sales Potential for Earthrings in the First 12 Months:

Are you willing to start with a consignment stock to launch Earthrings in your market?

Yes No

5. SUPPORTING DOCUMENTS

Optional at initial submission. You may upload company registration, tax/resale certificates, a company profile or territory information. PDF, JPG, PNG or WebP files only.

Supporting Documents:

6. AGREEMENT

I certify that the information provided is accurate and complete. I understand that Earthrings™ Prime Distributor positions are limited to 10 exclusive distributors in the USA and are subject to review and approval by Earthrings.

Authorized Signature: Printed Name: Title:

Date:

I confirm that the information supplied is accurate. I authorise Earthrings USA to review this application. I accept the Privacy Policy. I accept the Distributor Terms and Conditions. I understand that submitting this form does not guarantee approval.

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