HCI Partner Application

Heartland Capital Investments, LLC

Partner Application / On-Distributor Agreement
Contact Information
Legal Business Name*
DBA Name*
Contact Name & Title*
Business Address*

Street Address

Street Address Line 2

CityState

Zip Code
Office Phone

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Email*
example@example.com
Website
Business Information
Federal EIN (FEIN)*
Owner's Name*

First NameLast Name
In which state(s) do you conduct business?*
What products do you sell? Select all that apply.*

Portable BuildingsDecksSwing SetsCarportsPlayhousesGazebosMowersTractorsGolf CartsOther
Annual Sales*
Average Product Sales Price*
Date Business Was Established*

MonthDayYear
Date
Do you have a full-times sales force?*
Do you have brick and mortar dealerships? If so, how many?*
Do you sell products online?*
Do you currently offer rent to own as a purchasing option? (If yes, what company?)*
Do you currently offer financing as a purchasing option? (If yes, what company?)*
Trade References (Three References Required)
Business Name #1*
Contact Name*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Business Name #2*
Contact Name*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Business Name #3*
Contact Name*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Are you applying for inventory financing?*

YesNo
If applying for inventory financing, please fill out the following supplemental information:
Consent to obtain a copy of your personal credit report.
Principal's Name

First NameLast Name
Title
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
Date of Birth

MonthDayYear
Date
Please provide at least one of the following documents:

A. Copy of the most recent annual financial statement (Balance Sheet and Income Statement)

B. Copy of the most recent tax return or Schedule C from personal return if sole proprietor

Also please provide copies of company brochures and product pricing or links to where these can be found online.
Upload Relevant Documents Here*

Browse Files
PDFs are preferred Cancelof
Did a Sales Representative assist you? If so, include their name here:*

First NameLast Name
IN WITNESS WHEREOF, the parties execute this Agreement as of the date by the signatures. Rent to Own Contract terms will be discussed and included in the Welcome Packet. Welcome Packet will also include company procedures and settlement fundings. Agreement exiting must be by written notification with a 90 day advance notice from either party.
Company Name*
Sign:*
Printed Name:*
Title:*
Today's Date:*

MonthDayYear
Date
Should be Empty:

Heartland Capital Investments, LLC