DEALER APPLICATION DEALER APPLICATION LEGAL NAME: * DBA: * MAILING ADDRESS * MAILING ADDRESS MAILING ADDRESS MAILING ADDRESS City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal ADDRESS of RETAIL ESTABLISHMENT * ADDRESS of RETAIL ESTABLISHMENT ADDRESS of RETAIL ESTABLISHMENT ADDRESS of RETAIL ESTABLISHMENT City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal STORE PHONE NUMBER * OFFICE PHONE NUMBER * FAX NUMBER PRIMARY E-MAIL ADDRESS * INVOICE E-MAIL ADDRESS * WEBSITE URL FEDERAL TAX ID NUMBER * TYPE of BUSINESS * Please select oneProprietorship (Individually Owned)PartnershipCorporation YEARS IN BUSINESS * NUMBER OF EMPLOYEES STORE HOURS NEW JERSEY DEALERS RESALE CERTIFICATION NUMBER Without this number we must charge sales tax. DATE BUSINESS ESTABLISHED MM/DD/YYYY AT PRESENT LOCATION SINCE MM/DD/YYYY ANNUAL VOLUME of LAST YEARS SALES $ * PROJECTED SALES THIS YEAR $ * ESTIMATED HENDERSON SALES THIS YEAR $ * ORGANIZATIONAL STRUCTURE of COMPANY NAME of OWNER(S)/SHAREHOLDER % of OWNERSHIP PHONE NUMBER Date of Birth Social Security Number RESIDENTIAL ADDRESS RESIDENTIAL ADDRESS RESIDENTIAL ADDRESS RESIDENTIAL ADDRESS City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal plus1 Add More minus1 Remove CORPORATE OFFICERS/DIRECTORS - PRESIDENT NAME DATE of BIRTH Social Security Number PHONE NUMBER CORPORATE OFFICERS/DIRECTORS - VICE PRESIDENT NAME DATE of BIRTH Social Security Number PHONE NUMBER CORPORATE OFFICERS/DIRECTORS - SECRETARY NAME DATE of BIRTH Social Security Number PHONE NUMBER CORPORATE OFFICERS/DIRECTORS - TREASURER NAME DATE of BIRTH Social Security Number PHONE NUMBER Company Buyer NAME PHONE NUMBER Company Accountant/Bookkeeper NAME PHONE NUMBER If you are human, leave this field blank.
