GENERAL

Date:
Company Name:
Address:
City:	State/Province:
Country:	Postal Code:
Telephone:	Fax:
Contact Person:
Title:
Email:
Annual Sales, U.S. $:	Year Established:
Number of Employees:	No. of Sales Reps:

TYPE OF BUSINESS - CHECK APPROPRIATE CATEGORIES

Agent Distributor Licensor Manufacturer Retailer Other (please describe):

Do you have warehouse facilities? No Yes Size:

Please list geographic areas served. List all Countries/States/Provinces:

List type of products you are currently selling:

List type of industry/customer you currently sell to:

Are you interested in selling to additional markets? Yes No - If yes, list additional markets of interest:

List languages in which your company can communicate:

REFERENCES

Bank Reference:
Address:
City:	State/Province:
Country:	Postal Code:
Telephone:	Fax:

U.S. Company you have done business with:
Address:
City:	State/Province:
Country:	Postal Code:
Telephone:	Fax:

U.S. Company you have done business with:
Address:
City:	State/Province:
Country:	Postal Code:
Telephone:	Fax:

BRULIN PRODUCT LINE(S) WHICH INTERESTS YOU:

PROJECTED ANNUALIZED SALES VOLUME (IN U.S. DOLLARS) OF THESE PRODUCTS:
YEAR 1 - $
YEAR 2 - $

PLEASE TELL US SOMETHING ABOUT YOUR COMPANY NOT MENTIONED ABOVE: