Dealer Application Form

Company Name

DBA

Billing Address

(Please list all ship to locations on a seperate sheet)

Please complete the detailed information below and sign as specified. If an attachment is available with
your general information and bank/trade references, please indicate and attach. Thank you.

A/P Contact Name

A/P Phone

A/P Fax

I/We prefer to receive our invoices via

Fax

CFO Name

CFO Phone

CFO Fax

CFO Email

Email at

Phone

Fax

Type of Business Structure (Corporation, Partnership)

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

Fed Tax ID Number

Resale Number

(A copy of resale certificate is required)

# of Employees

Principals Name

Years In Business

Principals 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