Dealership Application Form

Please fill out all required information to apply for our dealership program

1. Personal Information

Full Name (required)
Email Address (required)
Phone Number (required)
WhatsApp Number

2. Business Information

Company Name (required)
Business Type (required) —Please choose an option—RetailerDistributorContractorManufacturerOther
Years in Business (required) —Please choose an option—0-2 years3-5 years6-10 years10+ years
GST Number

3. Location & Territory

State (required) —Please choose an option—Andhra PradeshArunachal PradeshAssamBiharChhattisgarhGoaGujaratHaryanaHimachal PradeshJharkhandKarnatakaKeralaMadhya PradeshMaharashtraManipurMeghalayaMizoramNagalandOdishaPunjabRajasthanSikkimTamil NaduTelanganaTripuraUttar PradeshUttarakhandWest BengalOther
City (required)
Complete Address (required)
Preferred Territory Coverage

4. Product Interest

Fire Resistant CoatingRed Oxide PrimerElectrical Cables Fire proof CoatingThermoplastic Road Marking PaintIndustrial Thermal Insulation ServicesHeat Resistant PaintFire Rated DoorsFire Retardant Coating Services

5. Business Capacity

Expected Monthly Sales Volume —Please choose an option—₹1-5 Lakhs₹5-10 Lakhs₹10-25 Lakhs₹25+ Lakhs
Investment Capacity —Please choose an option—₹2-5 Lakhs₹5-10 Lakhs₹10-20 Lakhs₹20+ Lakhs
Warehouse Space Available —Please choose an option—500-1000 sq ft1000-2000 sq ft2000+ sq ftNo warehouse space
Sales Team Size —Please choose an option—1-2 people3-5 people6-10 people10+ people

6. Additional Information

Previous Experience with Similar Products
Why do you want to partner with Ugam Technology?
References (Optional)

I agree to the terms and conditions and authorize Ugam Technology to contact me.