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Dealer Application
STATE RESALE TAX #:
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STATE BUSINESS LICENSE #: (NEED PHOTO COPY)
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BUSINESS NAME:
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MAILING ADDRESS:
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SHIPPING ADDRESS:
*
BUSINESS PHONE NUMBER:
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E-MAIL ADDRESS:
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OWNERSHIP TYPE:
*
CORPORATION
PARTNERSHIP
SOLE PROPRIETORSHIP
OWNER OR PRINCIPLE:
*
PAYABLES CONTACT:
*
STORE PURCHASER:
*
BANK NAME:
*
CONTACT NAME:
*
ACCOUNT #:
*
TRADE REFERENCE #1:
*
Please include the company name, contact at the company, your customer number (if applicable), and a phone number in which they can be contacted.
TRADE REFERENCE #2:
*
Please include the company name, contact at the company, your customer number (if applicable), and a phone number in which they can be contacted.
GUARANTEE OF PAYMENT:
*
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