Become a Dealer - Dynamic Diesel

New Customer Application
Business Name*
Business Phone Number*
Please enter a valid phone number.
Billing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Ship to a different address?*

YesNo
Shipping Address

Street Address

Street Address Line 2

CityState

Zip Code
Sales Tax Number *
EIN*
Contact Name*

First NameLast Name
Contact Email*
example@example.com
Contact Phone*
Please enter a valid phone number.
Business Facts:*

Sole ProprietorshipPartnershipCorporation
State of Incorporation*
Date*

MonthDayYear
Date
Is this Business Subsidiary*

YesNo
Franchise*

YesNo
If Yes, name parent or franchiser
Business Hours
How long in business?*
Number of Employees
Expected monthly purchase from DDPM Inc.
Accounts Payable Contact*

First NameLast Name
Attach Photos of Business and/or Business Documents*

Cancelof
PERSONAL DATA OF OWNER-OFFICERS-PARTNERS
1. Name*

First NameLast Name
Title*
Phone Number*
Please enter a valid phone number.
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Length of time at above address*
2. Name

First NameLast Name
Title
Phone Number
Please enter a valid phone number.
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Length of time at above address
PLEASE LIST OTHER WAREHOUSE DISTRIBUTORS OR MAJOR SUPPLIERS. (LIST AT LEAST 2)
1. Name
1. Phone Number
Please enter a valid phone number.
1. Address

Street Address

Street Address Line 2

CityState

Zip Code
1. Contact Name

First NameLast Name
Contact Phone Number
Please enter a valid phone number.
2. Name
2. Phone Number
Please enter a valid phone number.
2. Address

Street Address

Street Address Line 2

CityState

Zip Code
2. Contact Name

First NameLast Name
2. Phone Number
Please enter a valid phone number.
To assist sales staff while working with you, please indicate below what best describes your primary business.*

WholesalerRetailerInstallerOther
Comments
NOTE: APPLICANTS SIGNATURE ATTESTS FINACIAL RESPONSIBILTY, WILLINGNESS AND ABLITY TO PAY OUR INVOICES IN ACCORDANCE with the payment terms which may be granted and in accordance with DDPM Inc. Published terms and policies as may be revised from time to time.

Applicant also assumes responsibility for a bills contract in his name at the designed address, and, if required to collect delinquent accounts, all collection agency, attorney expenses and court cost.

The information given herein is for the purpose of obtaining a wholesale account and is warranted to be true. I/We understand that completion of this application does not constitute an offer to sell or an authorization to buy from DDPM Inc. I/We authorize the firm to whom this application is made (DDPM Inc) to investigate the references listed. I/We have read and fully understood the above.
Signature*

Clear
Name*

First NameLast Name
Title*
Date*

MonthDayYear
Date
Should be Empty:

New Customer Application

PERSONAL DATA OF OWNER-OFFICERS-PARTNERS

PLEASE LIST OTHER WAREHOUSE DISTRIBUTORS OR MAJOR SUPPLIERS. (LIST AT LEAST 2)