Request to be a Dealer

Company Name

First Name

Last Name

Email

Phone/Mobile

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Is your shipping address different from your mailing address?

Yes

No

Shipping Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Company Website URL

Other Company URL (e.g., Google Business Profile)

Type of Business

Please provide some basic information about your business.

If you are not a well company, what well and pump background do you have?

Do you have any questions or additional information you think would be useful?

What information do you want in our Dealer Locator tool?

I confirm that the company applying to be a Simple Pump Dealer is a valid business and has a license to operate legally in the location specified. I have read and agree to the Simple Pump Retail Dealership Terms and Conditions.