LIFT-ALL Home

Date of Application*: (ex. 02/02/2002)

Company*:

Mailing Address*:

City*: State*: AL AK AZ CA CO AR CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY Choose... Zip Code*: 5-digit format.

Phone Number*: 7-digit number.Minimum number of characters not met.7-digit number.

Fax Number*: You must have a fax number.7-digit number.7-digit number.7-digit number.

E-Mail Address: Website:

Type of Organization*: Choose... Corporation, State of Incorporation Partnership Proprietorship Please select one.State*: AL AK AZ CA CO AR CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY None Choose...

Date Organization Began Business*: (ex. 01/01/1983).

Sales History:

Sales Projected This Year*: $ Input integer only.

Sales for Last Year*: $ Input integer only.

Sales for Two Years Ago*: $ Input integer only.

Additional Branch Locations:

Name and Location of any Affiliate Companies:

 

Facility Information

Please complete additional pages for each facility after you complete this initial application.

 

Facility (Choose all that apply)*: Headquarters Branch Owned Leased Choose at least one.

Company*:

Mailing Address*:

City*: State*: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY Choose... Zip Code*: 5-digit format.

Shipping Address*:

City*: State*: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY Choose... Zip Code*: 5-digit format.

Phone Number*: 7-digit number.7-digit number.7-digit number.Fax Number*: You must have a fax number.7-digit number.7-digit number.7-digit number.

E-Mail Address Website:

Number of Employees at this Location*: Integer only. * Choose... Union Non-Union Choose One.

Acres of Land*: Integer only.

Square feet of Space in Building*: Integer only.

Are Parts Stocked at this Location?*: Choose... Yes No

Is Service Performed at this Location?*: Choose... Yes No

Retail Service Billing Rate per Hour*: $ Integer only.

Other Aerial Device and Digger Derrick Lines You Distribute:

Manufacturer Your Sales Territory:

Manufacturer Your Sales Territory:

Manufacturer Your Sales Territory:

Other Types of Equipment You Distribute:

Manufacturer Your Sales Territory:

Manufacturer Your Sales Territory:

Manufacturer Your Sales Territory:

 

Personnel Information

Ownership and Management:

Name*: Title*: Years with Organization*: Integer.

Name: Title: Years with Organization:

Name: Title: Years with Organization:

Name: Title: Years with Organization:

Parts and Service:

Name: Title: Years with Organization:

Name: Title: Years with Organization:

Name: Title: Years with Organization:

Name: Title: Years with Organization:

Sales:

Name: Title: Years with Organization:

Name: Title: Years with Organization:

Name: Title: Years with Organization:

Name: Title: Years with Organization:

 

Credit Information

Bank Reference:

Loan Officer*: Email Address*: Invalid format.

Bank Name*:

Mailing Address*:

City*: State*: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY Choose... Zip Code*: 5-digit format.

Phone Number*: 7-digit number.7-digit number.7-digit number.Fax Number*: You must have a fax number.7-digit number.7-digit number.7-digit number.

Supplier Credit References (Two required):

Supplier Credit Reference One:

Supplier Name*: Email Address*: Invalid format.

Mailing Address*:

City*: State*: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY Choose... Zip Code*: 5-digit format.

Phone Number*: 7-digit number.7-digit number.7-digit number.Fax Number*: You must have a fax number.7-digit number.7-digit number.7-digit number.

Supplier Credit Reference Two:

Supplier Name*: Email Address*: Invalid format.

Mailing Address*:

City*: State*: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY Choose... Zip Code*: 5-digit format.

Phone Number*: 7-digit number.7-digit number.7-digit number.Fax Number*: You must have a fax number.7-digit number.7-digit number.7-digit number.

 

Additional Information

Please include any additional comments you feel may be pertinent to this application.

 

LIFT-ALL, Inc., a Division of Hydra-Tech, Inc., will use the information provided to complete the initial steps in applying for distribution of LIFT-ALL® brand products. By checking "I agree", the applicant assumes responsibility of the truthfulness and fulfillment of all requirements within this Online application. By clicking "Submit", the applicant understands that a submitted application with the same merit as a signed copy will be sent to Hydra-Tech, Inc. and the application process will begin. All information received by LIFT-ALL remains strictly confidential.

 

I agree*

Name of Applicant*:

Title of Applicant*:

 

(If nothing happens, check all required fields above)

Please note: All field marked with a * are required before submission. Any field highlighted in red is either incorrectly entered or empty and must be completed before submission. If you tried to submit this form and nothing happened, check all areas marked with a * or hightlighted red.