GENERAL INFORMATION
(RED = Required Information)
Business Trade Name (DBA)
Business Legal Name (as it appears on business license)
Business Street Address (Street, City, State and Zip
Code)
Business Phone
FAX
E-mail
Business Web Site
Billing Address (if different (Street, City, State and
Zip Code)
Shipping Address (if different - Street, City, State and Zip Code)
Officer/Owner Name Title
Officer/Owner Name Title
DESCRIPTION OF BUSINESS
This company is a (Check one)
Sole Proprietorship
Partnership
Corporation
DUNS #
Federal Employer ID
Are you a franchise dealer for a major
manufacturer?
If so, which brands
Samson
Shure
Audio-Technica
Telex
Denon-Marantz
Other
Incorporated in the State of
Length of time operating under the above
name:
Length of time at the above address:
Number of Branches/outlets operated/managed
by you:
INDUSTRY REFERENCES
(Must be suppliers that are actively distributing related
industry parts to your business in the past 12 months;
preferably in
the U.S.A.)
Business Name, Address, City, State, Zip Phone
# Fax
# Account
#
Business Name, Address, City, State, Zip Phone
# Fax
# Account
#
Business Name, Address, City, State, Zip Phone
# Fax
# Account
#
PERSONAL CREDIT INFORMATION (Owner/Partnership)
Name on Credit Card Credit
Card #
Credit Card Payment is accepted for U.S. Dealers ONLY.
Home Address Name on Credit Card
City, State, Zip Billing Address on Credit Card
Home Phone
Social Security Number
Drivers License Number
Have you ever filed bankruptcy? Yes
No
Personal
Date Filed:
Current Status:
Business
Date Filed:
Current Status:
BANK INFORMATION
TAX EXEMPTION INFORMATION
Exemption Claimed (MUST select
one)
Resale
Other
Product or Service Rendered:
General Description of products to be purchased
by the seller:
Sales Certificate ID Number:
Name and Title of Applicant:
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