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About Us
Our Products
- Cube S
- CUBE M
- CUBE L
- CUBE XL
- CUBE UV AIR
- CUBE UV SURFACE
  - CUBE UV SURFACE
  - CUBE UV SURFACE+
- OZONE BOX
  - OZONE BOX
  - OZONE BOX+
How it works?
Distributors
Media
- News
- Videos
Contact Us

About Us
Our Products
- Cube S
- CUBE M
- CUBE L
- CUBE XL
- CUBE UV AIR
- CUBE UV SURFACE
  - CUBE UV SURFACE
  - CUBE UV SURFACE+
- OZONE BOX
  - OZONE BOX
  - OZONE BOX+
How it works?
Distributors
Media
- News
- Videos
Contact Us

Menu

About Us
Our Products
- Cube S
- CUBE M
- CUBE L
- CUBE XL
- CUBE UV AIR
- CUBE UV SURFACE
  - CUBE UV SURFACE
  - CUBE UV SURFACE+
- OZONE BOX
  - OZONE BOX
  - OZONE BOX+
How it works?
Distributors
Media
- News
- Videos
Contact Us

Distributor Application Online Form

PLEASE FILL IN EACH FIELD IN THE FORM BELOW:
Your personal information will only be used for contacting you regarding your application. We will not share this information with any third parties.

Your Title

Mr Mrs Ms Miss

Other [please specify] :

Home Address:

First Name:

Country

Zip/Postcode

Last Name:

Personal Email:

Personal Phone:

Personal Mobile:

Business Name:

Current Sales Region / Territory:

Registered Name [if different] :

Your Relationship to the Business:

Business Owner Director / Partner / Member 25% [or over] Shareholder Appointed Representative

Registered Address :

How much of the business do you own? :

Country:

Zip/Postcode:

How long have you been trading?

.

Email Adress:

Percent of Business Related to medical / disinfection equipment?

Phone Number:

No. Employees:

No. Stores/Dealers:

Current Brand Offering:

Current Sales Channels :

Industry [B2B] Retail Store Online Store Online Marketplace Healthcare Horeca Automotive

Nature of the Business:

Where did you hear of Cube Atomizers?

Desired Sales Region / Territory:

Do you have experience of medical / disinfection equipment and their use?

Yes No

Do you already have potential orders for the Cube Atomizers equipment?

Yes No

If yes, which manufacturers/products? [please specify] :

Please estimate number of units required as opening order :

Please estimate your forecasted sales per annum :

Any additional requirements? :

If you don't have any references or do not wish to disclose this kind of information, you may skip this step by leaving all the fields empty.

Supplier Name :

Supplier Name :

Start Date :

Start Date :

Supplier Address :

Supplier Address :

Country:

Zip/Postcode

Country:

Zip/Postcode

Email Address :

Email Address :

Phone Number :

Phone Number :

I confirm that all the information given on this application form is true and complete. I understand that any falsification or deliberate omissions may disqualify my application or lead to the termination of any future granted Distributor Agreement or Contract. I understand that this form is merely a screening and is in no means a Distributor Agreement or Contract and that my application is subject to references that are satisfactory to Cube Atomizers.

I confirm

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