BECOME AN ACTSAFE DISTRIBUTOR

Application form

Registered name of your company
Contact Name
Contact Telephone
Contact Email
Registration date

How many people do you employ?

How many of these work in a sales capacity?
How does your sales force operate? (Main target groups, frequency of visits etc)
Which geographical area(s) do you cover actively?
Please list below, in order of importance, the fields in which your company is active
Which companies do you represent, and which products do you sell?
Does your company have experience in Rope Access? Yes No

If yes, which of the following applies? Your company provides training Your company has a training centre The instructors certified according to IRATA, SPRAT or similar
Please give any additional information about your company that you think would be helpful.
Please provide details of bank references here.
Where did you learn about Actsafe and our products?
In an attempt to avoid spam, please type the text shown above in the box provided.