Form 9 Dealer Cancellation

Distributor / Dealer Change and Cancellation Request
This form must be completed by your territory distributor. If you are wishing to make changes to or cancel your dealer agreement your distributor has to be informed.
What is being requested*

Account Change RequestAccount Cancellation Request
What Change is requested

Address ChangeService Authorization Level Change RequestBusiness Name Change
Responsible Distributor Information
Date*

MonthDayYear
Date
Distributor GPA*
Distributor Name*
Distributor Contact Name*

First NameLast Name
Distributor Contact E-mail*
example@example.com
Distributor Contact Phone #*
Business To Apply Changes Too
Number of locations requesting changes

12345678910
Dealer #1 GPA*
to change or cancel
Current Listed Dealer Name #1 *
New Dealer Name #1
Dealer #2 GPA
to change or cancel
Current Listed Dealer Name #2
New Dealer Name #2
Dealer #3 GPA
to change or cancel
Current Listed Dealer Name #3
New Dealer Name #3
Dealer #4 GPA
to change or cancel
Current Listed Dealer Name #4
New Dealer Name #4
Dealer #5 GPA
to change or cancel
Current Listed Dealer Name #5
New Dealer Name #5
Dealer #6 GPA
to change or cancel
Current Listed Dealer Name #6
New Dealer Name #6
Dealer #7 GPA
to change or cancel
Current Listed Dealer Name #7
New Dealer Name #7
Dealer #8 GPA
to change or cancel
Current Listed Dealer Name #8
New Dealer Name #8
Dealer #9 GPA
to change or cancel
Current Listed Dealer Name #9
New Dealer Name #9
Dealer #10 GPA
to change or cancel
Current Listed Dealer Name #10
New Dealer Name #10
Dealer Contact Name*

First NameLast Name
Dealer Contact Email*
example@example.com
Dealer Contact Phone Number*

Area CodePhone Number
New Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Request Service Level Change to:

CC2 Limited Service DealerCC3 Full Service Dealer
Brief explanation of reason for request:*
Business Hour ID
Should be Empty:

Distributor / Dealer Change and Cancellation Request