EmailMe Form - Distributor Application

How Our Distributor Program Works

PREMIUM
• Purchase 6,000+ gallons of Pitch Black per month
• FREE use of our drop tank for the duration of your distributorship
• Company logo listed on our distributor scroll
• Company listed on our distributor map & directory

STANDARD
• Purchase less than 6,000 gallons of Pitch Black per month
• Rental of our drop tank for the duration of your distributorship
• Company listed in our distributor map & directory

Either way, we'll deliver the drop tank to you and help you get started. Grow your business on a brand you can trust. Pitch Black is a brand in high demand.

How to Apply:

• Must be completed by the applicant.
• Fill out this form from top to bottom, fields may change based on answers
• You'll receive a copy of your form submission to keep on file.
• Follow up in 1-2 weeks to check the status of your application.

IMPORTANT - You can save this form to return later, but you MUST save the web link given on the web page after saving. It will not be emailed to you. We do not have access to your temporary data or link saved prior to you completing the application. Copy and paste it for later. Applications can be saved up to 30 days. Data will be lost after 30 days.

We'll Review Your Application as Soon as Possible.

• Our team will email and/or call you.
• We'll finalize all paperwork.
• Your distributorship will begin on an agreed upon start date

Applicant Info

Company Name *

Type of Company

Main Representative *

First Last

Phone *

### - ### - ####

Email *

Make sure this email is correct so we can contact you. A copy of this application will also be sent to this email address.

Confirm Email

Permission to Contact *

I give 5 Star Industrial Coatings permission to send me emails.

Physical Address of Company Applying for Distributorship *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Please enter the address for the state in which you are incorporated.

Upload Your Certificate of Good Standing *

This can be obtained from your Secretary of State's website.

EIN # *

# of Overall Locations *

(Including your company headquarters)

# of Years in Business *

List products you currently sell (must include any sealcoat brands you're using): *

Business Plan

When can you start this distributorship? *

MM / DD / YYYY

Proposed Area of Coverage *

List the cit(ies) and/or zip codes for which you'd like to cover.

How many sales reps and/or support staff will you have to cover this area? *

(Including your company headquarters)

Name of Manager *

First Last

List the person that will be running the day-to-day distributorship activities.

Trade References

We may contact any of the companies you list below. Please list three companies you've done business with. These can be suppliers, customers or previous employers.

Company #1 Name *

Company #1 Address *

Company #1 Phone *

### - ### - ####

Contact Name *

First MI Last

Last date you worked with Company #1 *

(Date range i.e. month/yr - month/yr)

Company #2 Name *

Company #2 Address *

Company #2 Phone *

### - ### - ####

Contact Name *

First MI Last

Last date you worked with Company #2 *

(Date range i.e. month/yr - month/yr)

Company #3 Name *

Company #3 Address *

Company #3 Phone *

### - ### - ####

Contact Name *

First MI Last

Last date you worked with Company #3 *

(Date range i.e. month/yr - month/yr)

Have you ever been convicted of a felony? *

Yes

No

Please explain: *

Military Service

Did you serve in the military? *

Yes

No

Branch *

Thank you for your service.

Rank at Discharge *

Date range i.e. month/yr - month/yr)

When did you work for the military? *

What type of discharge? *

Honorable

Another kind (please explain)

Please explain: *

Upload any other document you'd like to include:
(i.e. references, cover letter)

Word or PDF Documents Only

DISCLAIMER & SIGNATURE

I certify that the information contained in this application is correct to the best of my knowledge. I understand that to falsify information is grounds for refusing to set up or continue a distributorship.

At the time of application, I attest that I have the legal right to reside and work in this country (proof required). I understand I must provide a current Business Certificate of Good Standing for my state with this application. I authorize any person, organization, or company listed on this application to furnish you any and all information concerning my previous business experience. I also authorize you to request and receive such information including, but not limited to, any criminal conviction on my record.

In consideration for this distributorship, I agree to abide by the rules and regulations of the manufacturing company, which rules may be changed, withdrawn, added, or interpreted at any time.

I also acknowledge that the distributorship may be terminated, or any offer or acceptance of distributorship withdrawn, at any time, by either myself or 5 Star Industrial Coatings, LLC, for any reason not expressly prohibited by law.

I also agree to the following for the duration of the distributorship: *

We will not alter or manipulate the Pitch Black sealcoat or other products in any way outside of what is specified in the manufacturing specs.

We will not sell any other brand of sealcoat.

We will not disparage or misrepresent the Pitch Black brand in any way to customers via written or oral conversations, social media, or any other marketing channel. Employees who are found doing so will be terminated.

The Pitch Black sealcoat brand prides itself on ethical business practices, high quality durability, and safe reliable ingredients. Manufacturers, contractors, government agencies and end consumers rely on the safety and integrity of the brand. Becoming a part of the Pitch Black family requires you to help protect those interests.

Your signature below indicates you understand and agree to all of the above.

Signature *

Clear

Date Signed *

MM / DD / YYYY