Dealer/Distributor Application

Fillout form below or download and fax or email.
							Company Name
						
							DBA (if different)
						
							Contact Person
						
							Address
						
							Phone
						
							Fax
						
							Federal Tax ID or Social Security Number
						
							Type of Business
						
							No. of Employees
						
							Date business established
						
							Corporation
						
  Yes

							State of Corporation
						
							Names, titles, and addresses of your three chief corporate officers
						
							Name and address of your resident agent – If applicable
						
							Partners
						
  Yes

							Names and addresses of the partners
						
							SOLE PROPRIETORSHIP
						
  Yes

							Are you sales tax exempt?
						
Yes

No

							Have you ever had credit with us before?
						
Yes

No

							If yes, under what name?
						
							Authorized purchasers
						
							Purchase order required?
						
Yes

No

			Trade References
				
			Reference #1
				
							Name (Reference #1)
						
							Address (Reference #1)
						
							Phone (Reference #1)
						
			Reference #2
				
							Name (Reference #2)
						
							Address (Reference #2)
						
							Phone (Reference #2)
						
			Reference #3
				
							Name (Reference #3)
						
							Address (Reference #3)
						
							Phone (Reference #3)
						
			Bank References
				
			Bank #1
				
							Account #1 
						
							Phone (Bank #1)
						
							Contact Person (Bank #1)
						
							Name of Bank (Bank #1)
						
							Address (Bank #1)
						
			Bank #2
				
							Account #2
						
							Phone (Bank #2)
						
							Contact Person (Bank #2)
						
							Name of Bank #2
						
							Address (Bank #2)
						
							Printed Name
						
							Title
						
							Date
						
			GENERAL TERMS AND CONDITIONS AND PERSONAL GUARANTEE
You may take the 2% discount as indicated on the bill if you pay the invoice by the 10th day outstanding.
All bills become payable in full on the 11th day of outstanding and if not paid in 30 days are considered past due.
A service charge of 2% per month will be added to all amounts billed if not paid by the end of the month.
No additional credit will be extended to past due accounts unless satisfactory arrangements are made with our credit department.
PERSONAL GUARANTEE: If the credit customer is a corporation, then those signing this application, whether signing as an officer or not, personally guarantee payment for all items purchased on credit by the corporation.
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Trade References

Bank References

GENERAL TERMS AND CONDITIONS AND PERSONAL GUARANTEE

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