Distributor Application Form

Please use the form underneath to apply to become a Bionic Batteries Distributor or Dealer.
Please note : all fields marked with an * have to be filled in before you can send the form.

Company Details
Your name*	Address
Company name*	Postal code
	City
	Country
Contact Details
Phone	E-mail*
Mobile*	Website
Fax
Additional information
Do you want to receive our catalogue and price lists ?	Languages spoken
YES NO	English Français Italiano Nederlands Deutsch Espagñol Other
Do you want to receive our newsletters ?	Remarks and/or questions you might have
YES NO
I am currently
A WHOLESELLER/DISTRIBUTOR A RETAILER

BIONIC BATTERIES ™
Macons bvba
Geelseweg 80 - 2250 Olen - BELGIUM
Phone : +32 14 25 92 84
Email : info@bionicbatteries.com
Web : www.bionicbatteries.com