BioStim® Distributor Questionnaire
  Fields marked with * are required

Your Name *


Title *
Company Name *
Company Physical Address *
Company Physical Address 2
City *
State/Province * * Zip Code/Postal Code
Company Mailing Address *
Company Mailing Address 2
State/Province * * Zip Code/Postal Code
Phone *
Email *
Website Address
How did you hear about BioStim?

Will you be the primary contact between BioStim and your company? YES NO

If NO, please indicate: Name Title
Are you an owner or manager of the company? YES NO
How long has the company been in business?
What type of business is the company?
How many employees does the company currently employ?
Who in your company is authorized to sign an agreement/contract?

Name: Title
What geographic area does the company distribute to:

Which products are you interested in distributing?

MicroDrip Drain Line – cartridges  (used with MicroDrip Dispenser)
MicroDrip Hygiene – cartridges (used with MicroDrip Dispenser)
BioPlug L – for high flow lift stations (used with BioFloater)
BioPlug CS – for low flow lift stations and sewer lines
BioPill – for indoor grease interceptors
Super Aug Pill – for outdoor grease traps
Drain Line BioFoam – 32 oz concentrate
Septic Saver
Drain Relief Pill (used with MicroDrip or alone in other drain lines)

How many units do you anticipate distributing?  Per month Per year

How do you plan on marketing BioStim products?


Please list 2 customer references:

Customer How Long?

Customer How Long?

By completing this questionnaire you give BioStim, LLC authorization to contact the references listed.

Additional Comments:

Thank you for completing the Distributor questionnaire, a representative of BioStim will be contacting you.