Dealer Application Form

Please fill out the following Dealer Application form. For security reasons, please call or fax us your credit card info.

General Company InformationBusiness Name*
Business Address*
City*
State
Country if not US
Zip*

Contact InformationEmail*
Phone Number*
Fax Number
Contact Person*
Title*

Organization InformationOperating as*

Number of years in business*
Federal Tax ID Number*
State Retail License Number*

ReferencesPlease list names and phone numbers of three Trade References (Parts or Tucker or WPS accounts if available):
1)
2)
3)

Supporting DocumentsPlease fax the following documents to us at 678 534 5793:

Proof of Business - Copies of your Federal Tax ID, Business License, State Tax ID or Sellers Permit
Photocopies of advertising or business cards.
Proof of location - Photos of your retail shop or kiosk

The more supporting documentation you provide, the faster we can process your dealer application.

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