Dealer Registration

General Information

Business Name *

D/B/A *

Company Type *

Individual/sole proprietor

C Corporation

S Corporation

Partnership

Trust/Estate

Phone Number *

Fax Number

Email Address *

Website

Cell Phone Number

Federal Tax ID * (9 letters without "-" #########)

Sales Tax ID *

Hours of Operation

Ownership

Billing Address

Street Address *

City *

State *

Zip Code *

Shipping Address

Same as Billing Address

Street Address *

City *

State *

Zip Code *

Names of Officers

President / CEO / Owner *

Direct Phone No. *

Purchasing Manager / Authorizing Entity *

Direct Phone No. *

Trade References

Company Name

Contact

Phone No.

Fax No.

Company Name

Contact

Phone No.

Fax No.

Company Name

Contact

Phone No.

Fax No.

Bank References

Institution

Account No. & Type

Phone No.

Fax No.

Signed By

Print Name Title Date

Attachments

Picture of store registration *

Picture of EIN number *

By checking this box, the Customer acknowledges that they have read, understood, and agree to the Terms & Conditions outlined in this Credit Application and Personal Guarantee Agreement.