DISTRIBUTOR REQUEST FORM  
Enter the challange code in the field before completing the form
All fields with * are required and must be filled out.
Request Date: 
10/23/2019
Reference Number: 
20191023125
Distributor Information
Distributor Name: 
   
Distributor Number: 
 -   
Distributor Email (For Confirmation): 
   
 
Request Submitted By: 
   
CUSTOMER INFORMATION / ORDER
Customer Number: 
   
 Customer Name: 
 
Order Number: 
   
Order Ship Date: 
TYPE OF REQUEST (SELECT ONE)
Type of Request: 
 
Is this order Value or Flex Priced:der Value or Flex Priced:
   Enter % if "Yes" is selected:  %
UPS INFOMATION
UPS Pick-Up: 
PRODUCT INFORMATION
Product Code
Line Number
Amount
  
Total: 
REASON FOR THIS REQUEST
MUST SELECT AN OPTION BEFORE SUBMITTING FORM
You have selected  to receive the DR