Dealer Application

Please fill out completely.  Any omission of information may delay processing.  All information is treated in strict confidentiality.

Company Name: *
Address:
City: 
State:
Zip:
Phone: *
Fax: 
E-mail Address: *
Firm is a: Sole Proprietorship Partnership C Corporation S Corporation
If Incorporated, in what state:
When:
Name/Address of parent Company, if any:
List Owners, Proprietors, Directors or Officers:

A. Name: Title: Yrs. with Firm:

B. Name: Title: Yrs. with Firm:

C. Name: Title: Yrs. with Firm:

List any additional officers, directors, or owners:
Type of Business:
Yrs. in business:
Territory Covered:
No.of Salespeople:
Branch Locations:
Annual Sales:
Do you have a formal advertising/marketing program? Yes  No
Do you have any stocking facilities?  Yes  No

Do you have any servicing staff? 

Yes  No
Does your firm use licensed electricians currently for installing products? Yes  No
If Yes, please provide electrician's name, address, phone and electrical license number: 
If No, explain: 
Please list your three main products currently represented:
Manufacturer: Address: Phone: Product: Yrs. Represented:
1.
2.
3.
Do you carry any competitive energy management products? Yes  No 
If Yes, please provide details:
What warranty or guarantee do you provide your customers?
Are you, or have you ever been, bonded?   Yes  No 
Have you ever filed for bankruptcy?  Yes    No 
If Yes, describe:  
Please detail your education, work, and/or other experience which  demonstrates your ability to act effectively as an Energy Sentry® Dealer.  Email or type below resumes of employees, Company brochures, or other information available which will help us in evaluating your company as a prospective Energy Sentry® authorized dealer. 
Please list three technical or business references we may contact regarding your qualifications, quality of work, and/or business integrity.
Name Phone Relationship
1. 
2. 
3. 

* indicates a required field

I certify that all information furnished on this form is true, complete, and correct to the best of my knowledge.  I understand that the information is subject to verification by Brayden Automation Corp. and each source is hereby authorized to provide Brayden Automation Corp. with such information.

THIS APPLICATION DOES NOT OBLIGATE EITHER PART IN ANY MANNER.