Dealer Application Form

Company Name*

DBA*

Billing Address*

Street Address Address Line 2 City State ZIP Code

A/P Contact Name*

CFO Name*

A/P Phone*

CFO Phone*

A/P Fax

CFO Fax

I/We prefer to receive our invoices via*

Fax

CFO Email*

Phone*

Fax

Type of Business (Wholesale, Retail, Jobber, etc.)*

Type of Business Structure (Corporation, Partnership)*

Fed Tax ID Number*

Resale Number*

(A copy of resale certificate is required)

#of Employees*

Years in Business*

Principal's Name*

Principal's Phone*

– All sales are conducted via credit card payment or online. –

Payment Types Accepted Include: Visa, Mastercard, American Express or Paypal

By checking this box I grant my signature on this document.

Date

You must submit a copy of your tax license before submitting application.*

Max. file size: 256 MB.