If you are interested in becoming a dealer, please e-mail capizzanoal@aol.com with the products you would like to carry.
We encourage you to please print, fill out and email or copy paste, fill out and email in order to expedite your inquiry in becoming a Distributor.
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- Minimum order required.
- Minimum stocking order required.
Payment terms are wire transfer of funds to include;
Freight, Insurance, Taxes, Duties and Bank Charges.
Territory desired __________________________.
Dental Burs Canada
Independent Distributor Application
41 Plainfield Rd.
Toronto, Ontario,
M9N-1G6, Canada
Email to capizzanoal@aol.com
Business Name:
Business Address:
Business Telephone No.:
Business Fax No:
Business Email Address:
Business Number:
Principal(s) Name(s):
Principal(s) Home Address(s):
Principal(s) Drivers License(s) for Signature Verification (attach photocopy)
References:
Bank Reference ( bank name, contact name, phone number and account number):
Trade Reference (Business name, contact name, phone number and account number,):
All of the information furnished on this application is to the best of my/our knowledge true, complete and accurate. The applicant authorizes Dental Burs Canada or its agent, to obtain and verify any financial, credit, and other information about the applicant and its
principal(s) with the references listed above and credit reporting agencies.
Name _________________________________________ Signature ________________________________
Submitted on the __________ day of __________ , in the year __________ .
