ENCON DEALER APPLICATION

COMPANY INFO

COMPANY NAME
CONTACT NAME (Person who should receive promotional information)
SOLE PROPRIETOR PARTNERSHIP CORPORATION
SHIP TO ADDRESS
BILLING ADDRESS/P.O. BOX
CITY
STATE
ZIP
PHONE
FAX
E-MAIL ADDRESS
HOW DID YOU HEAR ABOUT ENCON?	DOOR & ACCESS SYSTEMS WORLD FENCE NEWS FABRICATOR FENCEPOST Internet Trade Show Referral (Please specify who) Other (Please explain)

PRINCIPALS

AT LEAST ONE PRINCIPAL IS REQUIRED
NAME	TITLE
NAME	TITLE
NAME	TITLE
NAME	TITLE

BUSINESS INFO

TYPE OF BUSINESS
STATE CONTRACTOR'S LICENSE #(Required)
CITY BUSINESS LICENSE # (If Applicable)
RESALE # (If Applicable)
YEAR BUSINESS ESTABLISHED
NUMBER OF EMPLYEES

REFERENCES

PLEASE LIST THE SUPPLIER NAME AND PRODUCT PURCHASED THIS IS NOT A CREDIT APPLICATION
SUPPLIER NAME	PRODUCTS PURCHASED
SUPPLIER NAME	PRODUCTS PURCHASED
SUPPLIER NAME	PRODUCTS PURCHASED
TYPE OF EQUIPMENT REQUESTED FROM ENCON
PERSON(S) AUTHORIZED TO PLACE ORDERS

The undersigned represents that the above named company is an experienced and qualified installer of access control, communications, security and/or automatic gate equipment and acknowkedges that this representation is a condition of all sales by Encon Electronics. All warrantles and other commitments made by Encon Electronics as part of the normal sales process will be void and unenforceable if this representation proves to be false.

AUTHORIZED SIGNATURE	DATE
NAME(PRINT OR TYPE)	TITLE