Scooter Nation

Dealer Application
Phone: 305-599-0125 - Fax: 305.599-0925
 
Date: ___________________
Business name: ___________________________________________________  Phone No. ________________________
Address: ________________________________________________________   Fax No. __________________________
City:_______________________________________________  State / Providence:_______________________________
Zip / Postal Code: _____________________________  Email: ________________________________________________
 
Business Type:   Individual _____  Partnership _____  Corporation _____  Years in Business: _______
Sales Tax Exempt ID# ______________________________  Federal ID# or SS#________________________________
 
Owners Name: _______________________________________ Phone No. _____________________________________
Address: ___________________________________________________________________________________________
City, State, & Zip: ___________________________________________________________________________________
Description of Business: ______________________________________________________________________________
___________________________________________________________________________________________________
 
Bank Reference
Name:_____________________________________________  Account#: ______________________________________
Address:___________________________________________  Phone No.  ______________________________________
City, State, & Zip: ___________________________________________________________________________________
 
Business References
Name:_____________________________________________  Phone No. ______________________________________
Address:___________________________________________________________________________________________
City, State, & Zip: ___________________________________________________________________________________
 
Name:_____________________________________________  Phone No. ______________________________________
Address:___________________________________________________________________________________________
City, State, & Zip: ___________________________________________________________________________________
 
I authorize the above named companies to release any credit information concerning my account to Scooter Nation Inc..  I also swear
that all information contained herein is correct.
 
Signed: ________________________________________________________  Date: _____________________________
 
Please Do Not Write Below
Reviewed By: __________  Approval: NA ____ CA ____ CK ____  Date: ___________  Dealer # ___________________
 
Please fax this dealer application and a copy of your state business tax reseller number to Fax No.305.599-0925