Santiago Chopper, rolling chassis kits, Chopper parts Harley Davidson parts

Dealer Application

ATTENTION: If you forget to complete a field and submit the form, just hit back on your browser. All your information will still be there.

All field descriptions in RED are manditory to fill out. Please try to fill out the whole application to the best of your knowledge.
If you have any questions about any of the fields on the form please call 1-(813)-671-9097.

Legal Company Name:*
Date:*
DBA:*
Tax ID #:*
Street Address:*
Street Address 2:
City:*
State/Providence:*
Zip Code:*
Fax:
Business Phone:*
Pick One:*	Sole Proprietor Partnership Coporation
State Of Incorporation:
Business & Credit Reference
Name of Owners, Partners, and Shareholders:*	Must type at least one.
Bank Name:*
Phone:
Address:*
Address 2:
City:*
Zip Code:*
State/Providence:*
Contact Person:*
Account #:*
(Vendor should include 3 motorcycle distributors who currently accept your company check)
Vendor Name:*
Phone:*
Address:*
Address 2:
City:*
State/Providence:*
Zip Code:*
Account #:*
Contact Person:*
Vendor Name:*

Phone:
Address:*
Address 2:
City:*
State/Providence:*
Zip Code:
Account #:*
Contact Person:*

Vendor Name:*
Phone:*
Address:*
Address 2:*
State/Providence:*
Zip Code:*
Account #:*
Contact Person:*
Your Information
Store Manager:*
Parts Manager:*
Acountant:*
Parts Buyer:*
State Resale #:*
Do you require a purchase order?:	Yes No
:	ALL ORDERS NEED TO BE PREPAID BY CREDIT CARD, MONEY ORDER, OR CERTIFIED CASHIERS CHECK. NO C.O.D., NO COMPANY CHECKS, UNLESS SPECIAL AGREEMENT HAS BEEN ARRANGED. ALL INFORMATION PROVIDED IN THE ABOVE APPLICATION IS CORRECT TO THE BEST OF YOUR KNOWLEDGE. YOU KNOW THAT IT IS A FEDERAL CRIME TO PROVIDE FRAUDULENT INFORMATION ABOUT YOURSELF OR BUSINESS THAT YOU OWN.
Do you agree with the above statement.:*	Yes-I agree with the above statement. No-I do not agree with the above statement.
E-Mail Address:*