Dealers Application Form

Date

Buyer Identification

"Buyer" includes all subsidiaries, division and affiliates

First Name

Last Name

Trade name (if different)

Business Address

Federal EIN/Social Security No.

State Resale Cert. #

Business Type

Contact Names

Office Phone

Cell Phone

Fax

Dates Business Formed

Email

History

State Business Formed

Have you done business under any other name in the past 5 years?

Yes

No

With us?

Yes

No

Have you or any company with which you were associated in the past 5 years been subject to any bankruptcy or insolvency proceeding?

Yes

No

Are there any judgments or legal proceedings pending or threatened respecting Buyer or any Guarantor?

Yes

No

Company Principals-Owners

(All must be set forth below)

1.

Name

Title

Soc. Sec. No.

Drivers Lic. No

Home Address

Home Phone

2.

Name

Title

Soc. Sec. No.

Drivers Lic. No

Home Address

Home Phone

3.

Name

Title

Soc. Sec. No.

Drivers Lic. No

Home Address

Home Phone

Bank References

1.

Name

Address

Account #

Contact Name

Phone

Email

2.

Name

Address

Account #

Contact Name

Phone

Email

Trade References

1.

Name

Address

Account #

Contact Name

Phone

Email

2.

Name

Address

Account #

Contact Name

Phone

Email

3.

Name

Address

Account #

Contact Name

Phone

Email

Initial Project

Address

Tax Lot

Tax Block

Owners

Buyers Contract at Initial Project is with

Type

ALL SUBSEQUENT PROJECTS MUST BE SIMILARLY DESCRIBED FOR GOODS TO BE SHIPPED

Purchase Order Required

Yes

No

Requested Credit Line

This will not limit liability for greater amounts.

CREDIT INFORMATION:

Buyer and Guarantor(s) authorize (1) Seller to contact or to have others contact references and to obtain credit reports and make other credit inquiries about Buyer and Guarantor(s) now and in the future to update information so long as Buyer's obligations are outstanding and (2) such other sources chosen by Seller to provide similar information.

CREDIT CARD AUTHORIZATION:

Buyer and the undersigned hereby authorizes Seller to charge purchase of Buyer to the following credit card account:

Name on Account

Address of Cardholder

Name of Credit Card Issuer

Account Number

Security Code

Expiration Date

BUYER AGREES TO ALL OF THE TERMS AND CONDITIONS OF THIS DOCUMENT INCLUDING THOSE THAT FOLLOW THIS SIGNATURE ON THE NEXT PAGE

Dated

Witness

Buyer E-Signature

Title

I accept terms & conditionsView terms of use

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