Dealer - Contractor Enrollment Form
DEALER-CONTRACTOR NAME:
*
ADDRESS
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Federal Tax ID (EIN)
*
BANK REFERENCE
*
Name of Bank
Routing#
Account#
NUMBER OF LOCATIONS
*
1
2
3
4
5
6
7
8
9
10
PHONE NUMBER
*
-
Area Code
Phone Number
E-MAIL
*
YEAR OF ESTABLISHMENT
*
GROSS ANNUAL SALES
*
WHAT BRANDS/MAKES YOU SELL AND/OR INSTALL
*
NAME OF FACTORY / SUPPLIERSALES REP
*
CONTACT INFORMATION OF SALES REP
*
WHAT IS THE AVERAGE PRICE OF YOUR SALES
*
MONTHLY AVERAGE QUANTITY OF CREDIT APPLICATIONS
*
WHICH COMPANIES ARE FINANCING YOUR CREDIT APPLICATIONS?
*
PRINCIPAL/OWNER INFORMATION
*
First Name
Last Name
OWNERSHIP PERCENTAGE
*
DATE OF BIRTH
*
-
Month
-
Day
Year
SSN
*
ADDRESS
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Signed by
*
First Name
Last Name
Signature
*
Submit
Clear Form
Print Form
Should be Empty: