PTEAZER - DEALER AND DISTRIBUTOR APPLICATION

COMPANY PROFILE/DEALER AND DISTRIBUTOR APPLICATION


Company Name
Address
Shipping Address: (if different)
Billing Address
City
State
Country
Zip Code
Phone Number
Fax Number
Do You Have A Web Site?
Email Address?
At present location since (date)
Year Incorporated
State of Incorporation
Owner:
Owner Address
Soc. Sec. Number
Fed Tax ID No
Resale Number
Business License Number
Description of Company and Services it provides
Number of Stores and Locations
BUSINESS REFERENCES
BUSINESS REFERENCE Account No
BUSINESS REFERENCE Address
BUSINESS REFERENCE State
BUSINESS REFERENCE Zip
BUSINESS REFERENCE Phone
BUSINESS REFERENCE Fax
BUSINESS REFERENCE E-mail
BANK INFORMATION
BANK NAME
Account Number
Phone
I understand that this application granted only for as long as this account is in good standing