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Scooter Nation
Dealer Application
Phone:
305-599-0125 - Fax: 305.599-0925
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| Date: ___________________ |
| Business name: ___________________________________________________
Phone No. ________________________ |
| Address: ________________________________________________________
Fax No. __________________________ |
| City:_______________________________________________
State / Providence:_______________________________
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| Zip / Postal Code: _____________________________
Email: ________________________________________________ |
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| Business Type:
Individual _____ Partnership _____
Corporation _____ Years in Business:
_______ |
| Sales Tax Exempt ID# ______________________________
Federal ID# or SS#________________________________ |
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| Owners Name: _______________________________________
Phone No. _____________________________________ |
| Address: ___________________________________________________________________________________________ |
| City, State, & Zip:
___________________________________________________________________________________ |
| Description of Business:
______________________________________________________________________________ |
| ___________________________________________________________________________________________________ |
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| Bank
Reference |
| Name:_____________________________________________
Account#: ______________________________________ |
| Address:___________________________________________
Phone No. ______________________________________ |
| City, State, & Zip:
___________________________________________________________________________________ |
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| Business
References |
| Name:_____________________________________________
Phone No. ______________________________________ |
| Address:___________________________________________________________________________________________ |
| City, State, & Zip:
___________________________________________________________________________________ |
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| Name:_____________________________________________
Phone No. ______________________________________ |
| Address:___________________________________________________________________________________________ |
| City, State, & Zip:
___________________________________________________________________________________ |
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| Signed: ________________________________________________________
Date: _____________________________ |
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| Please Do Not Write Below |
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| Reviewed
By: __________ Approval: NA ____ CA ____ CK ____
Date: ___________ Dealer # ___________________ |
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| Print
Page |
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