Application for Membership
  • Company Name*
    0
  • Title*
    1
  • Company Principal*
    2
  • Email*
    3
  • Address*
    4
  • City, State and Zip*
    5
  • Mobile Phone*
    6
  • Business Phone*
    7
  • Company Website*
    8
  • Geographic Servicing Area*
    9
  • Approximate Annual Sales Total*
    10
  • Approximate Annual Sales - JanSan Products*
    11
  • Approximate Annual Sales - Other Products*Foodservice, Packaging, Hardware, etc...
    12
  • Number of Years in Business*
    13
  • Number of Employees*
    14
  • Do you qualify as a minority-owned business?*
    Yes
    No
    15
  • Are you a member of any other buying groups?*
    Yes
    No
    16
  • Please read and agree to the terms below.*
    I understand that checking this box constitutes a legal signature by an authorized company representative confirming that I acknowledge and agree to the Terms found in the NISSCO membership guidelines summary; that the organization is not affiliated with any other buying group and if so, it is the sole responsibility of the above company to handle all relevant resignation regarding those such affiliations. NISSCO agrees to keep all distributor information confidential absent contact information. Acceptance of application by NISSCO is not credit approval for preferred suppliers.
    17
  • 18
  • National Independent Sanitary Supply Companies

    NISSCO, LLC. 45662 Terminal Drive, Suite 200 Dulles, VA 20166-4340 800-229-9541 Download and read the NISSCO membership guidelines summary. www.nissco.com
    For more information, please contact Kim Allison-Foster at kallison@nissco.com
    19