Dealer Application Form Company Name*DBA*Billing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code A/P Contact Name*CFO Name*A/P Phone*CFO Phone*A/P FaxCFO FaxI/We prefer to receive our invoices via* Fax Email CFO Email*Phone*FaxType 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 Date Format: MM slash DD slash YYYY You must submit a copy of your tax license before submitting application.*
