Aegis Corporation New Dealer Application

Please complete this form in order that we can provide the appropriate information to you. The information you submit will be treated confidentially.

Aegis Corporation does not sell or otherwise distribute information about visitors to our web site or customers to any non-Aegis affiliated organization for any purpose whatsoever and unsolicited e-mail is never sent. Please see our Privacy Policy for additional information.


(*Required Field)  
First Name*  
Middle Initial  
Last Name*  
Street Address*  
Address (continued)  
State/Province (if applicable)*
Zip/Postal Code (if applicable) *
Country* Other:
Type Of Ownership*  
How many years in business?*   
Please provide the names of three current suppliers  
Supplier 1*  
Supplier 2*  
Supplier 3*  
Do you have a web site?*  
If yes, what is the URL?
Please select one or more product groups.*  
Are you presently selling radiation shielding products?*  
How should we contact you?*  
If by phone, what is the best time to reach you?


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