Business Opportunity Application. Complete this form for more information on Hygienitech dealership opportunities.









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DEALER APPLICATION

The application you're about to complete is in no way binding and it is used solely for the purpose of allowing us to know a little more about you. All information is confidential and kept in the strictest confidence. Once we receive your application and it is reviewed by our selection committee, we will contact you to discuss the next step in becoming a Hygienitech® Mattress Cleaning Systems dealer.

Please note that we have special leasing programs available.

* Indicates that the information in the field is required.
First Name:*
Last Name:*
Address:*
City:*
State/Province:* (US & Canada Only)
Zip/Postal Code:*
Country:*
Home Phone with Area Code:*
Office Phone with Area Code:	Optional
Fax Phone with Area Code:	Optional
Best time to contact you:*	Days Evenings
Email Address:*
Current Employer:	Optional
Title or Position:	Optional
Have you ever owned your own business?	Yes No (Optional)
If yes, please tell us a little about your business experience
What geographic area would you be interested in:*
How much time would you be devoting to the Hygienitech® business:*
When would you like to start your business:*
Amount of working capital available to launch your business:*
Additional Comments

Hygienitech® does not collect information for marketing purposes, nor will we share your information with others. All information is confidential and kept in the strictest confidence.

If you prefer you can print a copy of this form, fill it out completely and fax it to Hygienitech at: 561-381-4206

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