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 Customer Service»   UK Dealer Registration Form

UK Dealer Registration Form

This application form is only to be filled out for intended dealers only!

Please use the form below to send us the products of interest to yourselves with as much information as possible in order to make your application successfull.

Please fill in all areas so we can asses your application thoroughly.
We will reply to all applicants in due course for further information if required for dealership.
Owner / Your Name *
Company/Business Name *
Phone/Contact Number *
Email Address *
Company/Business Website *
Company or Home Address *
Type of Business *
Do you have a Showroom?. *
If "YES" What is it's Sq Ft?
How long have you been in business? *
Please provide a short description about your company. *
Please list the products that you service/sell. *
How did you hear about Cimuka products & Crescentquail?  *
Please describe your current interest level in becoming a Crescentquail Basement Dealer. *
What market do you service? What is your geographic reach?  *
What is your annual sales volume? *
Planed start-up Budget? *
Group product's of interest? *
What is the answer to the question below?
Enter a number e.g. 4 or 7
This is to help us protect our website against spam and abuse.

It also means we can deal with your enquiry quickly since all mails received are from legitimate visitors.