License Request : Glendon Biofilter Technologies

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	Glendon_® Information Request

* Required information

Company Name:

Address:

City:

State, Postal Code:

Country:

Phone number:

Fax Number:

Email Address:

Owners:

Name*	Title/Function*	% Owned*

Years experience in on-site system industry:

Number of Employees:

List all onsite licenses currently held:*

List all industry related companies you have ever been or are currently associated with as an employee, representative or dealer and dates of affiliation:*

Name(s) of persons to be licensed and type of license, installer or O&M:*

Approximate number of designs and/or installations you accomplish each year:

Glendon® designs and/or installations you anticipate in the first year:

Two industry references (names and phone numbers):

*
*

Two credit references (names and phone numbers):

*
*

If we accept your application we will send you a license for you to review and complete prior to receiving training. After successful completion of training, your name will be posted on our web site and your license will be active in accordance with its terms and conditions.
Thank you for your interest in Glendon®.