AUTHORIZED DEALER APPLICATION FORM

NAME & ADDRESS

Legal Company Name

Mailing Address

Billing Address

City

State

Zip Code

D&B No

D&B Rating

Phone number

Fax

Email

Purchasing Contact

Zip Code

Purchasing Email

Accounts Payable Contact

Accounts Payable Phone

Accounts Payable Email

COMPANY PROFILE

No. Years in Business

Annual Sales

No. Locations

Organization

Name

City/State

Officers / Principals

Owner

Owner Hm Address

Owner Phone

President / CEO

President Hm Address

President Phone

CFO

CFO Hm Address

CFO Phone

Tax

Resale No.

Tax ID Number

TRADE REFERENCES

Comment

BANK REFERENCES

Name

Owner

Checking Acct #

Loan #

Branch

Contact

Savings Acct #

Line of Credit #

City

Authorized Signature

By signing below, we agree to Mount to Coast Terms & Conditions.

Authorized Signature

Title

Date

Personal Guarantee

The undersigned, in consideration of Credit made by Mount to Coast to the Debtor, hereby absolutely and unconditionally guarantees to Mount to Coast the punctual payment in full of all sums due.

Signature

Name

Date

Home Address

Home Phone

Witness Signature