Primary Contact Information

Primary Contact Name*

First

Last

Primary Contact Title*

Primary Contact Phone*

Phone Extension (if needed)

Primary Contact Email*

Company Contact Information

Company Name*

Owner's Name*

Street Address*

City, State and Zip*

City

State

Zip

Company Phone Number*

Phone Extension (if required)

Company Email*

Company Website*

Business Information

What specific product(s) are you interested in selling?*

What is your annual dollar sales volume (DSV)?*

Projected DSV for current year?*

DSV Last year?*

DSV Two years ago?*

DSV Three years ago?*

What is your company’s market share percentage in your industry?*

Who are your three largest competitors?*

Who are your top three U.S. customers, based on sales volume?*

Is your company Electronic Data Interchange (EDI) capable?*

Will you provide free of charge samples of your product(s) to Ascent upon request?*

Does your company have the capability to facilitate a drop ship/bill to across stores nationwide?*

Can you extend credit terms to franchise store partners?*

What is your fill rate?*

Does your product have a warranty? *

If yes, how long and what does the warranty cover?

What is your company's liability insurance levels?*

Do you name your customers as additional insured?*

Is your product tested to UL safety standards?*

If your product contains lithium, is it UN T1:T8 Certified?*

Submit

This is not an application to become a Batteries Plus Bulbs/Ascent vendor. If your business is selected, there will be another process to qualify you as an approved supplier. Our buying team receives hundreds of prospective vendor requests a year, so it is important that this form be filled out completely and correctly. It takes time to review these submissions, so please be patient. You will receive a notification that your submission has been received. Fees may apply for application and qualification.