Dealer Application

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Please complete this form to apply as an ALAC Dealer.

* Indicates Required Field

Company Name *

Title *

Your Name *

Address *



Email *

Contact Number *

Fax Number

Accounting Contact

Purchasing Contact

Marketing Contact

Company Classification

Years in business

   Business Type

How would you classify your company? (Check All That Apply)

Analytical Equip. ManufactureSystem IntegratorConsultant Valve ManufactureEngineering CompanyDistributor Gas ManufacturerLab Design/BuilderE-Commerce

Select vertical markets of specialization (Check All That Apply)

Oil and GasUSA MedicalCanada Gas IndustryEurope Environmental LabAsiaOther

Prior Year Annual Revenue

Percentage of Revenue (Totals to 100%)

Hardware: %
Software:  %
Services:  %

Current Projected Revenue

Which geographical areas do you serve?

Local (50 miles)State wideRegionalNationalInternational

Total Number of Employees

Inside-Sales:    Outside-Sales:    Engineers:

Indicate which type of marketing activities you engage in (Check All That Apply)

SeminarsNewslettersTrade ShowsDirect ResponsePrint AdsOthers


Please provide a description of your primary "value added" services

Please list other primary vendors you have a formal relationship with.

Additional Comments


By submitting this form, I agree to the terms of the Reseller Agreement. *

Contact our Partner Manager if you have problems submitting this form, or you have any questions.