New Distributor/Account Form
Fill out the form below for... fields marked with
**
are required.
**
Effective Date
**
Region
Select One
1221 - Darren Standbridge
1230 - Sergio Avila
1240 - Tony Dejesus
1250 - Tom Zuckett
1260 - Tim Nelson
1521 - Steve Soroko
1522 - Andre Maule
1531 - Danny Sanders
1532 - Johnny Wong
1533 - Abdel Balkhir
1541 - Daniel McNairy
1542 - Adolfo Blanco
**
Regional Manager
First / Last Name
Wilden
Typhoon
Spectrom
OEM Account
Unitec
Saniflo
BioPharm
Other
**
Primary Market Area
i.e. Northern California
**
Shared PMA
yes
no
PMA Terms & Conditions
**
Distributor ID #
**
Company Name
**
Branch Location
Select One
Main Location
Satellite
Home Office
**
Mailing Address
**
Shipping Address
Address
Address
Office / Suite
Office / Suite
City / State / ZIP
(No abbreviations e.g. Saint not St.)
City / State / ZIP
Country:
Country:
Website
i.e. www.yourcompany.com
**
General Email
**
Main Phone
Main Fax
Sales Phone
Sales Fax
Accounting Phone
Accounting Fax
**
Accounting Email
Distributor Contact Information
First / Last Name
Title
Direct Phone/Cell Phone
Email
Contact Type
Receives-TGIF email
Receives-the EDGE
Teamwilden-Approved
Teamwilden- Acct Mngr
CVT member
DVT member
Acctg
Sales
Literature
Subdistributor
Partner Portal Approved
Receives-TB's
Key
Key-sec.
Branch Mngr
Mngr Asst.
First / Last Name
Title
Direct Phone/Cell Phone
Email
Contact Type
Receives-TGIF email
Receives-the EDGE
Teamwilden-Approved
Teamwilden- Acct Mngr
CVT member
DVT member
Acctg
Sales
Literature
Subdistributor
Partner Portal Approved
Receives-TB's
Key
Key-sec.
Branch Mngr
Mngr Asst.
First / Last Name
Title
Direct Phone/Cell Phone
Email
Contact Type
Receives-TGIF email
Receives-the EDGE
Teamwilden-Approved
Teamwilden- Acct Mngr
CVT member
DVT member
Acctg
Sales
Literature
Subdistributor
Partner Portal Approved
Receives-TB's
Key
Key-sec.
Branch Mngr
Mngr Asst.
First / Last Name
Title
Direct Phone/Cell Phone
Email
Contact Type
Receives-TGIF email
Receives-the EDGE
Teamwilden-Approved
Teamwilden- Acct Mngr
CVT member
DVT member
Acctg
Sales
Literature
Subdistributor
Partner Portal Approved
Receives-TB's
Key
Key-sec.
Branch Mngr
Mngr Asst.
First / Last Name
Title
Direct Phone/Cell Phone
Email
Contact Type
Receives-TGIF email
Receives-the EDGE
Teamwilden-Approved
Teamwilden- Acct Mngr
CVT member
DVT member
Acctg
Sales
Literature
Subdistributor
Partner Portal Approved
Receives-TB's
Key
Key-sec.
Branch Mngr
Mngr Asst.
First / Last Name
Title
Direct Phone/Cell Phone
Email
Contact Type
Receives-TGIF email
Receives-the EDGE
Teamwilden-Approved
Teamwilden- Acct Mngr
CVT member
DVT member
Acctg
Sales
Literature
Subdistributor
Partner Portal Approved
Receives-TB's
Key
Key-sec.
Branch Mngr
Mngr Asst.
First / Last Name
Title
Direct Phone/Cell Phone
Email
Contact Type
Receives-TGIF email
Receives-the EDGE
Teamwilden-Approved
Teamwilden- Acct Mngr
CVT member
DVT member
Acctg
Sales
Literature
Subdistributor
Partner Portal Approved
Receives-TB's
Key
Key-sec.
Branch Mngr
Mngr Asst.
