Business Name: ________________________ Phone:
Business Name: ________________________ Phone: _______________
Street Address: ________________________ Fax: ________________
City, State & Zip: ________________________ E-Mail: ________________
Owner/Principal: ________________________ Year Established ________
Resale or Fed ID #: _____________________ # of Locations: _________
Do you sell ____ Wholesale or ___ Retail ?
What type of customer do you sell? ________________________________
( consumers, installers, hot rodders etc.)
Please List 3 Wholesale Trade References:
-----------------------
Company Name: __________________________ Phone: ______________________
Street: _________________________________ Fax: ________________________
City, State, Zip: ___________________________ $ / year: _____________________
Company Name: __________________________ Phone: ______________________
Street: _________________________________ Fax: ________________________
City, State, Zip: ___________________________ $ / year: _____________________
Company Name: __________________________ Phone: ______________________
Street: _________________________________ Fax: ________________________
City, State, Zip: ___________________________ $ / year: _____________________
[pic]
Fax this completed form to: 573-785-7717
Upon approval we will fax or e-mail you your password for our on-line dealer site.
PO Box 1351 Poplar Bluff, MO 63902-1351
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