Distributor Application Form

Lubchem, Inc. is currently looking for distributors to carry the many products we offer. If you are interested in becoming a distributor, please complete and submit the following form. This form must be completed in its entirety before distributorship may be considered. Once received, application will be reviewed by Lubchem management and a written response will be returned within five business days.

Your Privacy

This information is for our use only and will not be distributed or sold in any form.

Your Company Information

Company legal name:
Years in business:
Physical address:
City:	State: Zip:
Mailing address (if different than above):
City:	State: Zip:
Phone:

Market Information

Current products and/or services offered by your company:

Current territory:
Years in current territory:
Anticipated territory expansion:
Annual sales:
Forecasted sales growth %:
Forecasted annual sales of Lubchem products:

Reason(s) for choosing Lubchem products:

How many sales employees does your company now employ?
How many sales personnel will be responsible for selling Lubchem products?

Service Information

Does your company employ service personnel? If so, how many?

Does your company have experience lubricating, sealing, or performing online valve maintenance? If so, please specify:

Enter code above