Dealer Application

Date:_____________________

 

1. COMPANY PROFILE

Name of Firm:_________________________________________________________________________________________________________________________

Tel:_________________________________________________________ FAX:___________________________________________________________________

Street Address:_______________________________________________________________________________________________________________________

City:__________________________________________ State:_____________ Zip:____________________

We are set-up as a:[ ]Proprietorship [ ]Partnership [ ]Corporation

Name & Home Address of Proprietor or of Partners (Please Print)

a. Name:__________________________________________________________ Title:__________________

Address:________________________________________________________________________________

City:________________________________________________ State:_____________ Zip:______________

 

b. Name:__________________________________________________________ Title:_________________

Address:_______________________________________________________________________________

City:________________________________________________ State:_____________ Zip:_____________

 

If Corporation, Officers' Names:

President:_______________________________________________________

Buyer:__________________________________________________________

Payables:________________________________________________________

Date Business Established:______________ How long at present location:_________________________

Federal Tax ID #:_______________________________ Resale Number:__________________________

2. BANK REFERENCES

Name:___________________________________________________________ Tel:____________________

Address:________________________________________________________________________________

City:_______________________________________________ State:____________ Zip:________________

Type and Number of Account: [ ]Checking [ ]Savings

3. TRADE REFERENCES

a. Name:_________________________________________________________ Tel:____________________

Address:________________________________________________________________________________

City:______________________________________________ State:______________ Zip:_______________

FAX:_________________________________________ Credit limit:____________________

b. Name:_________________________________________________________ Tel:____________________

Address:________________________________________________________________________________

City:_____________________________________________ State:_______________ Zip:_______________

FAX:_________________________________________ Credit limit:____________________

c. Name:_________________________________________________________ Tel:____________________

Address:________________________________________________________________________________

City:_____________________________________________ State:______________ Zip:________________

FAX:_________________________________________ Credit limit:____________________

AUTHORIZED SIGNATURE:___________________________________ TITLE:_______________________ DATE:________

Customer shall be responsible for all legal and collection fees in regard to this account. No returns allowed without RMA number. No refunds allowed after 30 days from the date of invoice. There will be a $25 charge for any returned checks. 1.5% finance charge will be applied to any invoice which is past due. There will be a $30 diagnosis charge for items returned as defective and test good.

 

Consent Form Authorization

This form may be reproduced or photocopied and that copy shall be as effective consent, as the
original which I/we signed.

SIGNATURE:___________________________________________

SIGNATURE:___________________________________________

DATE:_________________________________________________

COMPANY NAME:_______________________________________________________________

I hereby give my/our consent to have Incode Corp. obtain any and all information concerning my/our
checking and/or savings accounts, obligations and all other credit matters which may be required in
connection with my/our application for a dealership and/or credit from Incode Corp..

 

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