Form

Potential Supplier Questionnaire
Company Name*
Full Name*
First Name Last Name

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number*
- Area Code Phone Number
E-mail*
Website

Briefly describe your product(s)*

Briefly explain the competitive advantage of your product(s)*

Is your product packaged for aftermarket distribution (labeling, packaging, UPC, etc.)*

Yes No
Is your product*

Manufactured in the USA Imported
Is your product application driven*

Yes No
Do you consider your product(s) to be an automotive related item*

Yes No

Do you have printed catalogs*

Yes No
Is it available in an industry recognized database? (Activant, Triad, etc)*

Yes No
Please explain*

Do you currently sell your product(s) to other retailers?*

Yes No
Company 1
Company
Since
Month Day Year

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Company 2
Company
Since
Month Day Year

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Company 3
Company
Since
Month Day Year

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Additional Comments
Upload a file

Upload a File
Is your product stocked in any O'Reilly location?*

Yes No

Please tell us which O'Reilly location*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

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