New Dealer Registration Form

DEALER APPLICATION FORM

Please fill in the form below.
Legal Business Name*
Tax Resale Number:*
Website*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Shipping Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Store Contact*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Major Brands Carried*
Number of years in Business*

Buyer Information
Product Buyer Name*

First NameLast Name
Product Buyer Email*
example@example.com
Phone Number*

Area CodePhone Number

Photo of TAX ID Document

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Photo of Store OUTSIDE FRONT*

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Photo(s) of Store INSIDE

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Enter the message as it's shown*
Should be Empty: