Old Java Distributor Application Form

Distributor Application Form


Company Name *)

Contact Person *)	Title First Name Last Name

Address *)

Country *)

Post Code

Phone ) Phone number must be entered as Country Code/ Area Code/Phone Number.*	- -

Fax ) Fax number must be entered as Country Code/Area Code/Fax Number.*	- -

Email *)

Are you ...?	Wholesaler Retailer

Website

Briefly describe your business.

What is your container volume (40ft) per annum ...? *)

Do you import from other companies in Indonesia...?	Yes No

Notes