IKP DEALER APPLICATION FORM

Thank you for interest in becoming a dealer for IKP. Please complete the application below. This information will be used ONLY by IKP and will not be sold to any other company. This information is used strictly for contact with IKP and order processing.

Once this infomration is collected and reviewed, you will be notified via email that you have been accepted as an IKP dealer and may then order from this site using your dealer account. You will not be able to order from IKP as a dealer until this application has been accepted by IKP.

COMPANY NAME:
TYPE OF COMPANY:
TAXPAYERS ID:
SALES LICENSE NUMBER:
DATE ESTABLISHED:
COMPANY CONTACT:
ADDRESS:
ADDRESS 2:
CITY:
STATE:         ZIP CODE:    
BUSINESS ZONING:
PHONE NUMBER:
FAX NUMBER:
EMAIL:
WEBSITE:

Please complete the following reference information.
REFERENCE 1:
COMPANY NAME:
DOING BUSINESS SINCE:
ADDRESS:
CITY:
STATE:         ZIP CODE:    
PHONE NUMBER:

REFERENCE 2:

COMPANY NAME:
DOING BUSINESS SINCE:
ADDRESS:
CITY:
STATE:         ZIP CODE:    
PHONE NUMBER:

Please complete the following information to create an IKP Customer Account. This account will allow you to track and view all current and past orders.
ACCOUNT USERNAME:
SECRET WORD:
CUSTOMER NUMBER: 031010033016