Dealer and Distributor Application

Dealer and Distributor Application
Legal Business Name: *
DBA: *
Physical Address: *

Street Address

City State / Province

Zip Code Country
Delivery Address: *

Street

City State / Province

Zip Code Country
Bill To Address If Different Than Above:

Street

City State / Province

Zip Code Country
Phone: *
Email Address: *
Fax: *
Check One: *

Sole Proprietor Limited Liability Corporation Partnership Corporation Trust
Number of Years in Business: *
Date Business Started: *

Month Day Year
State Incorporated: *

Street Address

Street Address Line 2

State / Province Incorporated

Country
TIN/FEIN:
TIN/FEIN
Owners or Executive Officer (If There Are More Than Two, Please Attach an Additional List.)
Owner/Executive Officer #1: *
Title: *
Owner/Executive Officer #2:
Title:
Person to Contact Regarding Financial Matters:
Name: *
Email *
Title: *
Phone: *
Person to Contact Regarding Buying Decisions:
Name: *
Email *
Phone: *
Please indicate if you are a dealer or a distributor: *

Dealer (I would like to sell GameGuard in my store.) Distributor (I would like to sell GameGuard for special events.)
Resale Certificate Attached? No Yes*
Tax Exemption Certificate Attached? No Yes*
Upload Tax Exemption or Resale Certificate:

Cancel of
Other Brands Currently Carried: *
Interests: *

Department Golf/Resort Hunting/Fishing Outdoor Specialty Supply Other
Contacted By Sales Rep? Name (Leave Blank If No):
How Did You Hear About Us? *
Authorized Signature: *

Clear
Printed Name: *
Date: *

Month Day Year
Should be Empty: