Distributor/Customer Information Form

Term 2005 - 2022 must be filled out completely and printed on company letterhead in order to be processed)

San Dimas, California. USA

Name of entity:*

Address of entity’s principal place of business or headquarters: *

Years in Business:*

Website address

Main email address*

Country Locations of Entity’s offices worldwide*

List worldwide country locations or places where you ship the goods (Final Destination).

Names and titles of entity’s ultimate parent company and individuals with controlling ownership

Names of entity’s subsidiaries if any

Names of Entity’s Directors, Senior Management, CFO/CEO, President, Treasurer, General Managers

Contact person, phone andfax of Three Business Referenes (e.g. Other U.S. Companies)

Record of any Penalties or Proceeding Under U.S Export or Sanction Laws:

Any Other Relevant Information

Contact Details