Dealer

Dealer Application Form

1. Business Information Business Name Business Address

City

State

ZIP

Business Phone

Business Email

Website

Type of Business (check one)

Sole Prop

Partnership

Corporation LLC

Other

If Other, please specify Years in Business Owner/Principal Name(s)

Federal Tax ID / EIN

Resale/Dealer License #

2. Contact Information Primary Contact Name

Title

Phone

3. Business Operations Products/Brands Currently Carried

Estimated Monthly Purchasing Volume

Number of Employees

Territory/Market Served

4. Trade References

Reference 1

Company

Contact

Phone

Reference 2

Company

Contact

Phone

5. Agreement & Signature

By signing below, applicant certifies that all information provided is true and correct and authorizes verification of this information.

I certify the information above is accurate and authorize verification.

Printed Name

Title

Date

Submit application

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