Contact STAIN-X®

AMI/STAIN-X
PO Box 259662
Madison, WI 53725-9662
1.608.268.2090
Fax: 1.608.274.3839

jmach@stain-x.com

Customer Service

Monday - Friday
8 am - 4:30 pm CST

Please call:
1.877.478.2469



Retailer Application Form

Retailer Application - STAIN-X®

Please fill out of the information being requested accurately.

Please complete all required fields.

Full Company Name

Contact Name

Address

City

State

Zip Code

Phone Number

Email Address

Year Established or Incorporated

Type Of Business

Corporation  Proprietorship  Partnership  LLC

Bank References - Please include bank name and contact information.

Busines and trade references. Please include company name, address, phone number, and contact.

How did you hear about us?

Customer Request  Internet  Trade Publication  Other

If you heard about us freom a trade publication, which one?

If you heard about us in any other way please explain.

What information are you requesting? Please check all that apply.

Product Information on STAIN-X  Product Information on other STAIN-X products  How to become a stocking retailer  MSDS sheets

AMI/STAIN-X understands that the information on this form is for the purpose of obtaining business credit with AMI. WE will not provide this information outside of this scope to any other party. By agreeing to this you are authorizing AMI to contact any or all of the references you have provided. It is also assumed that all information you provided is accurate. By agreeing to these terms you are authorized by your company to make monetary decisions for that company.

I (We) agree and understand the terms  I (We) do not agree with the above stated terms

Company Position

CEO\Owner  Vice President  Manager\Dept Manager  Other

If other please explain your position.