Distributor Inquiry Form
If you would like to become a distributor fill out the form below. Or, you may download the distributor information form in PDF format and mail it to us at:

The Brulin Corporation
2920 Dr. A.J. Brown Ave.
Indianapolis, IN 46205
Your Contact Information
First Name
Last Name
Email Address
Company Information
Company Name
Address
City
State/Province
Country
Postal Code
Telephone
Fax
Company Website:
Year Established
Number of Employees
Number of Sales Employees
Does your company have additional sales offices or branches?
What is your type of business?
Other:
Do you have warehouse facilities?
Do you have other facilities (ie: laboratory, blending, packaging)?
If yes, in which cities or provinces?
Please enter the regions where you have good sales coverage or upload a map.
Click "Browse" to upload your map:
Your Market Information
What type(s) and brand(s) of checmical products does your company sell?
What other type of products does your company sell?
To which industries or types of customers do you sell?
Do you have plans to grow your business to new markets (industries or regions)?
Product Interest
What Brulin Product Line(s) are of interest to you?
What Brulin products are of interest to you?
What is your company's total yearly sales turnover (indicate currency):
Other
Is there anything else about your company that you would like to tell us?