Zero Mini Split Dealer Form

Section 1: Company Information

Business Name

DBA (if applicable): Business Address:

DBA if applicable

Business Address

Phone Number

Format: (000) 000-0000.

Email Address

Website

Years in Business

Corporation Type of Business:PartnershipSole Proprietor

Contact Name

TitlePosition

Phone Number

Format: (000) 000-0000.

Email Address

Section 3: Business Operations

Number of Employees: Service Area (Counties/Cities): Do you currently sell HVAC or Mini Split systems?YesNo If yes, which brands?: <$10,000$10,000-$25,000 $50,000+ $25,000-$50,000 Estimated Monthly Sales Volume:

Number of Employees

Service Area CountiesCities

If yes which brands

Section 4: Resale Tax Information

Resale Tax ID Number

State of Issuance

Upload Resale Certificate

Section 5: Licensing and Certification

Contractor License Number

License Expiration Date: EPA Certification Number:

License Expiration Date

MonthDayYear

EPA Certification Number

Upload License Insurance Documents

I hereby certify that the information provided above is true and complete. Iunderstand that submission of this form does not guarantee approval as an authorized dealer. Signature:Date:

Signature

Date

MonthDayYear