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ATA MEMBER
Procain Company
P.O. Box 878
Fogelsville, PA US 18051
(877) Pro-Buck
DISTRIBUTOR APPLICATION
PROCAIN LLC
Please read and complete the follwing: Distributor Application, Terms and Conditions, and Distribution Agreement.
Click here
for a printable version of this order form.
Date:
Doing business as:
Whom to contact:
Address:
City:
State:
Zip:
Employer ID Number:
Fax:
Telephone:
Pager:
E-mail:
Legal Name:
Select one:
Individual
Corp.
Ptshp.
Liab. Co.
Distributor Agreement
This Distributor Agreement is by and between Procain LLC, a Pennsylvania Limited Liability Company with a place of business at 800 Mountain Road, Hamburg, Pennsylvania 19526 (the ''Manufacturer''), and
of
,
(“Distributor”). In consideration of the mutual covenants herein and intending to be legally bound hereby, the parties agree as follows:
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TERMS
I agree to the terms
I disagree to the terms
IN WITNESS WHEREOF, the parties have caused this Agreement to be executed by their duly authorized officers this
day of
, 20
.
“Manufacturer”
PROCAIN LLC, a Pennsylvania Limited Liability Company
By:
(SEAL)
Name:
Title:
“Distributor”
By:
(SEAL)
Name:
Title:
*
Check here for agreement and electronic signature.
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Required
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