CUSTOMER REGISTRATION – Kos Distribution

CUSTOMER REGISTRATION FORM

Contact Name

Job Title

Phone

Business Name

Business License Number

Business Type

Manufacturer, distributor, broker, etc)

Website

Business Address

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

Preferred Payment Method

Credit, ACH, Net Terms, etc.

Estimated Monthly Purchase Volume

Product of Interest

Do you require delivery?

If yes, preferred delivery days/times:

Do you have a loading dock?

How did you hear about Kos Distribution?

Are you interested in promotional or marketing support?

Any additional comments

By submitting this form, I confirm that the information provided is accurate and that our business complies with all applicable regulations.