Distributor Application

Distributor Application
Personal Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Social Security #
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Own of Rent
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Information
Registered Business Name
DBA (if applicable)
Entity Type
How long in business?
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone

Area CodePhone Number
Product Sold
Avg # of Units Sold Per Month
Present Finance Company
For the purpose of approving this application or furthering an ongoing business relationship, you are authorizing Merchants Acceptance Corp. to conduct a general investigation and to periodically check my credit history, employment history, criminal record, and banking records, etc.
Signature
Should be Empty:

Personal Information