Licensee Opportunities

If you are interested in becoming a licensee of Applied Polymerics, completely fill out this form and press submit. A representative from Applied Polymerics will contact you promptly by email or phone.

 

 

Company Name:

Address:

Phone Number:

Email Address:

Website Address:

Company Officers:

Type of Business:

Annual Revenue:

Customer Base:

 private commercial government

Equipment Listing:

Number of Employees:

Sales Force?

 yes no

Number of Sales People:

Licensed in which states?

Type of License:

Is Company Bondable?

 yes no

Amount of Insurance Coverage:

References (list three):



Are you willing to submit a financial statement?

yes no