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 Request Account Cancellation Request
What Change is requested

Address Change Service Authorization Level Change Request Business Name Change
Responsible Distributor Information
Date *

Month Day Year
Date
Distributor GPA *
Distributor Name *
Distributor Contact Name *

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

1 2 3 4 5 6 7 8 9 10
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
New Business Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Request Service Level Change to:

CC2 Limited Service Dealer CC3 Full Service Dealer
Brief explanation of reason for request: *
Should be Empty:

Distributor / Dealer Change and Cancellation Request