Distributor Application  
For consideration to be a distributor, please fill out all fields in the application and questionnaire sections.

Application
Personal Information  
First Name        MI
Last Name
Address
City
State        Zip
Date of Birth
Email
Home Phone #  
Cell Phone #
Work Phone #
Fax Phone #
Are you married? Yes     No      If yes, spouse's name
Will you have other owners/partners? Yes     No      If yes, partner's name 

Employment Desired
Are you self-employed? Yes     No      (if so, please complete the information below)
Name of Company/Employer
Salary Desired
Are you: Unemployed     Retired

Financial Information
Total Liquid Assets Available
(e.g. cash, stocks, bonds, mutual funds)		 A
Total Tangible Assets
(e.g. house, car, business, etc.)		 B
Total Assets (add A to B) C
Total Liabilities D
Total net worth: Total assets minus total liabilities
(subract D from C)		 E
Personal Information
1. Have you ever filed for bankruptcy protection? If yes, identify discharge date. Yes     No    
2. Have you ever been convicted of a felony? Yes     No
3. Have you ever been associated directly or indirectly with terrorist activities? Yes     No
4. Are you or anyone in your immediate family a partner or owner (partial or otherwise) If yes, list name of business and family relationship. Yes     No
5. Are you or anyone in you immediate family currently under any form of non-competition agreement that limits your right to operate any business? Yes     No
Professional Background
Current Occupation/Title
Length of Employment
Self-employed Yes     No
Name of Company
Business Phone Number
Address
City
State         Zip
Please give a brief review of last 5 years of employment
Personal References Professional References
Name Phone Name Phone

Geographical Trade Area(s) of Interest
City State County Country

Questionnaire

  1. What image do you have of this company its industry?

  2. What type of products and services have you sold and how did you sell them?

  3. What type of books do you read?

  4. What self improvement classes or courses have you attended since leaving you formal education?

  5. Do you feel it is necessary to have written goals? Why or why not?

  6. Have you reached your full potential? if not how far do you have to go to be content?

  7. What is a career experience that demonstrates your work ethic?

  8. What is the biggest success in your career so far?

    1. How did you achieve that success, and were you able to repeat it?

    2. Could you teach others how to achieve the same results?

  9. Could you teach others how to achieve the same results?

    1. Are you meeting your goals currently?

    2. What is your reason for seeking opportunity elsewhere?

  10. Where do you see your career in 5 years? Describe in detail, including income level.

    1. What will your goals be?

    2. What, if any, would be a reason to leave that position?

  11. Imagine you are in complete control, and you could decide your position and income level, what would you choose? Describe in detail.

"I certify that the facts contained in the application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws."

Date (mm/dd/yy)  

If you would like to include your resume, please check this box
Please send your resume as an attachment to matt@energydoctorinc.com.

By checking this box, you verify that all the information above is accurate to the best of your knowledge


Return To Previous Page
 
xxx

Home  |  About Us  |  FAQ  |  Energy Guard  |  Products  |  Energy Savings  |  Calculator  |  Testimonials  |  Contact Us  |  Site Map
1478 NE 69th Place  |  Ankeny, IA 50021  |  Ph. 1-866-963-9681  |  Fax 1-515-289-0645
| All Content Copyright EnergyDoctorInc.com | Website Designed By EDJE technologies |