New Dealer Application Profile

Profile

Name of Business: *

Sale Tax Exemption #:

Name of Applicant: *

FED ID or SS #:

Address: *

City: *

State: *

Zip: *

Telephone:

Fax Number:

Email:

Organization Form: *

Your Title: *

Your Percent of Ownership: * %

Business

Describe the type of business you are operating: *

How many years have you been in this business: * years

What are the primary services you offer your customers: *

How many retail outlets do you operate: *

Is your business affiliated with a chain store or franchise operation: *

Yes

Name of chain or franchise:

Number of years affiliated: years

Where did you hear about us: *

Credit Information

For expedited approval, please provide fax numbers below! No COD References.

Name of Bank:

Contact Person:

Bank Phone:

Bank Fax:

Business Trade Reference:

Contact Person:

Reference Phone:

Reference Fax:

Complete Mailing Address:

Ever file bankruptcy or had involuntary Bankruptcy filed against business:

If so, please list when.

Authorization

AUTHORIZATION, OF INVESTIGATION, & RELEASE OF INFORMATION
I authorize investigation of all statements contained in this profile. I understand that misrepresentation or omission of facts called for is cause for non-consideration for a Dealership Account. I understand that this profile is not intended to be a contractual agreement of any kind. I authorize the release of financial information to you from my listed references.

Authorize

Date: *

What code is in the image?: *

Enter the characters shown in the image.

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New Dealer Application Profile