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Application For Proposed Dealer

SafetyMate, Inc.
1642 McGaw Avenue
Irvine, CA 92614

Toll Free: 1-800-439-8995 x104
Direct: 949.252.1570
Fax: 949-955-3529
Email: info@safetymate.com

Please use the form below to application request

Dealer Information
*Legal Name of Proposed Dealer
(Ex: 800-555-1212)
(Ex: 800-555-1212)
Corporate Information
*Form of entity, including place of formation
Year
Employee Categories of work
*Geographical area serviced by Applicant
Bank Information
(Ex: 800-555-1212)
(Ex: 800-555-1212)
Professional Information
*Experience as a Distributor, including in field of health care and first response devices.
 
*Facilities, including office, warehouse, and exhibit space