Dealer Questionnaire

Registered Business Name:

Individual Name:

Federal Tax:

Shipping Address:

City:

State:

Zip:

Business Phone:

Fax:

Cell Phone:

Email:

Type of Business:

Partnership
Proprietorship Corporation

State of Incorporation:

Date of Incorporation:

Addresses of Other Locations:

Officers, Partners or Owners:

1) Name

1) Title

2) Name

2) Title

3) Name

3) Title

Trade References:

1) Address:

1) Contact

1) Phone

2) Address:

2) Contact

2) Phone

3) Address:

3) Contact

3) Phone

Term Requested:

COD
Bank Floor Plan

Sales:

Floor Plan Financial Institution:

1) Address:

2) Address:

Broker: (Canadian Dealers)

Name:

Phone

Fax

Lines to be Handled:

Retro
Throwback Mt. McKinley

List Major Products Now Selling:

1) Product Name:

2) Product Name:

3) Product Name:

Comments:

Applicant Name:

Applicant Title:

Application Date:

Applicant E-Signature
By clicking the checkbox above you are electronically signing your application.