Membership Application

Please complete the form below to inquire about DPA membership.

* indicates required information

* I am a...

Distributor

Supplier

* Company Name:

Website:

* Contact Person:

Contact Person's Title:

* Email Address:

* Phone:

Fax:

* Address:

* City:

* State:

* Zip:

Estimated Annual ($) Sales:

# of Years in Business:

# of Employees:

What product categories are you currently doing business in?

Industrial Packaging Supplies (Cushioning, Shrink, Stretch, Tape, etc.)

Janitorial/Sanitary Supplies (Can liners, Chemicals, Mops/Brooms, etc.)

Restoration Supplies (Dehumidifiers, Truck Mounts, Wands, etc.)

Safety Equipment & Clothing (Eye Protection, Gloves, Hi-Vis, etc.)

Other (describe below)

What industries do you currently sell to?

Industrial Packaging Supplies (Cushioning, Shrink, Stretch, Tape, etc.)

Janitorial/Sanitary Supplies (Can liners, Chemicals, Mops/Brooms, etc.)

Restoration Supplies (Dehumidifiers, Truck Mounts, Wands, etc.)

Safety Equipment & Clothing (Eye Protection, Gloves, Hi-Vis, etc.)

Other (describe below)

We currently sell our products to:

Distributors Only

End-Users Only

Both

Are you a member of another buying group?

Yes

Which ones?

Comments:

Distributor Partners of America