RESELLER APPLICATION

Please complete and submit the following form. In the alternative feel free to contact us direct!

  1. Print this form and mail it to: 
    EcoChem
    CP Box 1388
    Hanna, AB,
    Canada T0J 1P0
  2. Print this form and FAX it to  403-364-2889
  3. Contact us by telephone at 403-364-2888  /  403-364-2802
  4. Email:
Tax Resale#/GST number:
Company Name: (required)
Type of business:
Email: (required)
Contact Person:
Name of Owner:
Address 1: (required)
Address 2:
Address 3:
City: (required)
Province/State: (required)
Postal Code: (required)
Country:
Store phone: (required)
Store fax:
Number of employees:
Number of store locations:
Years in business:

Annual sales Revenues:
Will you demonstrate EcoChem Products?
Will you offer technical support?
How often do you advertise?

How do you advertise? (Primary)

How do you advertise? (Secondary)
Your name:

Your title:


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