Distributor Portal Account Request Form

Company Name*

Your Name*

Enter your first and last name.

Your Job Title*

Enter your job title.

Email Address*

Enter your email address.

Phone Number*

Add your phone number in case we have a question.

Why do you need access to our eCommerce Portal?*

Select as many options as you like.

Select or enter value

You selected "Something Else."*

Tell us why you're requesting access so we can better understand any issues.

Is your company a Garlock distributor?*

Select

Why are you interested in becoming a Garlock distributor?*

Help us understand why your company would like to partner with Garlock to offer our high-quality sealing products.

How much revenue do you anticipate generating from Garlock sales as a new distributor?*

Estimate your first year sales revenue for Garlock products.

Select

What is your company's address?*

Use this format: 1666 Division St, Palmyra, NY 14522

Does your company currently have access to our eCommerce Portal?*

Is there anyone at your company using our Portal to see pricing or place orders?

Select

We will contact an Admin to get you access ASAP.*

Is there anything else you need help with in the meantime?

How can we help?*

Let us know what you're looking for or the problem you're trying to solve and we will do our best to help!

Will you be your company's User Administrator?*

Every company must designate a person with the authority to set up new users and give them access to purchase on behalf of the company. (You can have more than 1 admin!)

Select

User Adminstrator*

Who should be the User Administrator at your company?

(First and last name)

User Adminstrator's Email Address*

What is the email address of the person who will be your admin?

User Administrator's Job Title*

What is the job title for the person who will be the User Administrator?

Will your company be ordering products and shipping them internationally?*

This includes Canada and any location outside of the US.

Select

How many locations does your company have?*

Select

Who should we work with to verify your locations?*

Can we send you the locations we have on file or should we work with someone else at your company?

What is the address of your first location?*

Use this format: 1666 Division St, Palmyra, NY 14522

What is the address of your second location?*

Use this format: 1666 Division St, Palmyra, NY 14522

What is the address of your third location?*

Use this format: 1666 Division St, Palmyra, NY 14522

What is the address of your fourth location?*

Use this format: 1666 Division St, Palmyra, NY 14522

What is the address of your fifth location?*

Use this format: 1666 Division St, Palmyra, NY 14522

Which shipping carrier do you use for PARCEL orders shipping from PALMYRA NY?*

example: FedEx Ground

Which shipping carrier do you use for PARCEL orders shipping from HOUSTON TX?*

example: FedEx Ground

Which shipping carrier do you use for LTL Freight orders shipping from PALMYRA NY?*

example: R+L Carriers

Which shipping carrier do you use for LTL Freight orders shipping from HOUSTON TX?*

example: R+L Carriers

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