We are recruiting distributors who have the ability to grow with our product line.

Completing this Distributor Application Form ensures that you become part of our formalized distributor recruitment process.

We would ask that you complete this form in detail. A qualified Impacto representative will call you.

Please tell us about yourself

Name

First                                                  Last

Position

Company

Street

State/Province

Town/City

Zip/Postal Code

Country

Phone

(###)###-####
Ext:

Fax

(###)###-####

EMail

Website

Please tell us about your company

Number of sales people in your company?

 

What Countries do you service?

 

Does your company currently sell any other protective products?

Yes No

 

If yes, which companies do you represent now?

 

What is the best time to contact you?

 

Do you wish to receive Industrial Safety News from Impacto?

Yes No

 

We'd like to hear your questions about becoming an Impacto Distributor.