Dealer and Distributor Application

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

Street Address

CityState / Province

Zip CodeCountry
Delivery Address:*

Street

CityState / Province

Zip CodeCountry
Bill To Address If Different Than Above:

Street

CityState / Province

Zip CodeCountry
Phone:*
Cell Phone for Inventory Alerts:*
Email Address:*
Fax:*
Check One:*

Sole ProprietorLimited Liability CorporationPartnershipCorporationTrust
Number of Years in Business:*
Date Business Started:*

MonthDayYear
State Incorporated:*

Street Address

Street Address Line 2

CityState / Province Incorporated

Zip CodeCountry
RFC for International Shipping:
TIN/FEIN/RFC *
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.)
Sales Tax Exemption Certificate Attached? No Yes
Resale Certificate Attached? No Yes
Upload Sales Tax Exemption and Resale Certificate:*

Cancelof
Other Brands Currently Carried:*
Interests:*

DepartmentGolf/ResortHunting/FishingOutdoorSpecialtySupplyOther
Contacted By Sales Rep? Name (Leave Blank If No):
How Did You Hear About Us?*
Authorized Signature:*

Clear
Printed Name:*
Date:*

MonthDayYear
Should be Empty: