Application for Jones dealers & distributors

Application for Jones dealers & distributors
Jones Bicycles
1010 Benson Way Ashland OR 97520
phone: (541) 535-2034
email: jonesbikes@jonesbikes.com
website: www.jonesbikes.com
I am applying to be a/an*

H-Bar DealerH-Bar and Frameset DealerJones Bikes Distributor
Business Name*
DBA (if different)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Website*
Date Business Established*

MonthDayYear
Date
Federal Tax ID #*
Resale license/Retail #*
Insurance Provider*
Insurance Policy #*
Principal Owners*
Principal Owners Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Trade References

Please provide 3 references below
Business Reference #1*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Account #*
Business Reference #2*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Account #*
Business Reference #3*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Account #*
Authorization

The undersigned certifies that he/she is authorized to execute this document and that all statements are correct. Verification may be obtained from any source named in the application.

The undersigned has read and agrees to the dealer requirements.
Authorized Signer*
Title*
Date*

MonthDayYear
Date
Question/Comments
Should be Empty: