Please Print, Fill Out The Dealer Application Form & FAX To: (714) 842-7571
Or Mail To: PTEAZER Inc, Inc. 18291 Gothard Street Huntington Beach, CA. 92648

COMPANY PROFILE/DEALER APPLICATION

Company Name: __________________________________

Address: __________________________________

City:__________________________________ State:____ Zip: ___________

Telephone: _____________________

Ship To Address If Different: ____________________________

Fax:______________ Countries Email:______________ Website: _____________________

____ Corporation ____ Proprietorship ____ Partnership ____ DBA ____ Year Business Established

Principal(s): _____________________ Title: ___________

Principal(s): _____________________ Title: ___________

Fed Tax ID:___________ Resale No.:___________ Bus. Lic. No.: _____________________

Soc. Sec. No.: _____________________

Principle Business: ____% Retail ____% Wholesale ____ Number of Retail Outlets ____% Mail Order

____% Internet ____% Jobbers ____% Auto Dealers ____% Export

_____________________ Countries

Primary Business Area(s): __________________________________________

Vehicles Specialized: _______________________________________________

Do You Publish Your Own Catalog: ____ Yes ____ No ____ Issues Per Year ____ Distribution

Magazine Advertisement: ____ Yes ____ No ____________________ Magazine ____ Times Per Year

________________Magazine ____Times Per Year _______________ Magazine ____Times Per Year

BUSINESS REFERENCES:

Name: __________________________ Account No. Contact __________________

Address:__________________________ State_______________ Zip_______________

Phone:_______________ Fax:_______________ Email: _______________

Name: __________________________ Account No. Contact __________________

Address:__________________________ State_______________ Zip_______________

Phone:_______________ Fax:_______________ Email: _______________

BANK INFO:
Bank: Account No. __________________________

Phone:_______________ Fax:_______________ Email: _______________

Authorized Signature:_______________________________ Printed Name: __________________________

Permission is hereby granted to PTeazer Inc. for the release of information regarding the above bank account number and business references for the purpose of evaluation of this application.

By:_____________________________ Signed:_______________________________

Date:____________