First Name:
|
Last Name:
|
Business Title:
|
Organization:
|
Business Address:
|
City, State, Zip:
|
Business Phone:
|
Other Phone:
|
Fax:
|
Email:
|
Sales Tax Number:
|
| Do you operate multiple locations? If so, please list them. |
Location 1:
|
Location 2:
|
Location 3:
|
Location 4:
|
Location 5:
|
Location 6:
|
Do You Own or Lease Your Business Location?
|
How Many Years Have You Been In Business?:
|
The minimum dealer opening order is 6 units. Are you willing to place an opening order?
Yes No |
Dealers are required to have service facilities to assemble and maintain our products. Do you have a service facility?
Yes No |
Veloteq Corporation and/or its Authorized Distributors may require additional information using third party verification. Do we have your permission to request such information?
Yes No |
| |
