DISTRIBUTOR REQUEST FORM  
All fields with * are required and must be filled out.
Request Date: 
12/23/2024
Reference Number: 
2024122343
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