Daytona Helmets

Download Dealer Application

DEALER APPLICATION

Legal Company Name:

Date:

Doing Business As:

Street Address:

City:

State:

Zip:

Phone #:

Fax #:

Email Address:

Website Address:

Billing Address:

Federal ID#:

Resale #:

Type Of Ownership (Check One):

Individual

Partnership

Corporation

LLC

Name Of ...

Owner Partner Officer

Home Address:

City:

State:

Zip:

Home Phone #:

Social Security #:

Driver's License #:

Name Of ...

Owner Partner Officer

Home Address:

City:

State:

Zip:

Home Phone #:

Social Security #:

Driver's License #:

Store Manager:		Accessory Manager:
Parts Manager:		Book Keeper:
Description/Type Of Business:
Motorcycle:	V- twin Metric ATV Snowmobile
Accessory Store	Repair ShopExporterOther - Explain:

Franchise Dealer For:

Harley-Davidson Honda Kawasaki Suzuki Yamaha

BMW Ducati Arctic Cat Polaris Other

Store Hours: Monday-Friday:

From

To

Saturday:

From

To

Date Business Started:

Is A Purchase Order Required With Each Order?

Yes No

Do You Sell Mail Order Or Via Internet?

Yes No

Requested Method Of Payment: COD/Company Check Credit Card

TRADE REFFERENCES

1.Company Name:

City:

State:

Zip:

Phone #:

Fax #:

2.Company Name:

City:

State:

Zip:

Phone #:

Fax #:

3.Company Name:

City:

State:

Zip:

Phone #:

Fax #:

4.Company Name:

City:

State:

Zip:

Phone #:

Fax #:

I Hereby Affirm That All Of The Above Information Is Correct
Print Name:		Date:
Signature: