Page 2

RE: Euro-American Dealer Application Form

DEALER:_______________________________

Prepared By:______________________________

4.

FINANCIAL REFERENCES

Bank Name:______________________________

Contact Name:__________________________________

Bank Address:____________________________

Telephone or Fax Number:_______________________

5.

MARKETING DATA

Annual Sales Volume:_____________

Do You Maintain a Retail Store?_______

No. of locations:______

Actual Sales Territory Serviced:_________________________________________________________________

Telephone:____ Over the Road:____ Retail Clerks:____

Type of Sales Force:

(Please check all applicable boxes)

Commissioned Reps:____ Sales Associates:____ Franchise Dealers:____ None:____ OTHER:__________

Type of Advertising You Do:

(Please check all applicable boxes)

Local Newspaper:_____ National Magazines:____

Television:_______ Radio:_______ Brochures:_______ Mailers:_______ Catalogs:_______ OTHER:________

Do You Attend Trade Shows to Purchase Products:________________ (YES or NO)

To Sell Products:________________ (YES or NO)

Shows You Primarily Attend:_____________________________________________________________________

Entities You Sell To:

(Please check all applicable boxes)

Retail Customers:_____ Government:_____ Dealers:_____

Briefly Identify the anticipated Value of ERC Products to Your Sales Program:__________________________

______________________________________________________________________________________________

6.

ADMINISTRATIVE DATA

(Please check all applicable boxes)

Corporation:_____ Partnership:_____ Sole Proprietor:_____

Do You Issue Formal Purchase Orders:___ (Y/N)

Do You Pay by Credit Card:___

What Card(s):_________

Name(s)/Title(s) of Those Authorized to Sign Purchase Orders:______________________________________

Do You Currently Warehouse Products:___ (Y/N)

If Yes, How Much Floor Space Do You Have:_____Sq.Ft.

7.

SIGNATURE OF AUTHORIZED OFFICIAL:____________________________________

DATE:____________

PRINTED NAME:_______________________________________________

TITLE:______________________