AUTHORIZED DEALER APPLICATION FORM ... - FutureVideo
AUTHORIZED DEALER APPLICATION FORM ... - FutureVideo
AUTHORIZED DEALER APPLICATION FORM ... - FutureVideo
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<strong>AUTHORIZED</strong> <strong>DEALER</strong> <strong>APPLICATION</strong> <strong>FORM</strong>Company NameDBAAddressCity State/Prov Postal CodeCountry Tel FaxCompany Principal(s)Purchasing Mgr.Accounting Mgr.Tax Resale # State/Prov Years In BusinessNumber Of Branches(Important: Attach locations/Managers names for dealer listing)Applying for: _____Open Account _____C.O.D. Account _____Authorized Dealer StatusPRINCIPAL BUSINESS DESCRIPTION____ Professional/Industrial Video Dealer____ Computer Graphics/Multi-Media Dealer/VAR____ Photo/Video Retailer____ Consumer Electronics Retailer____ Foreign Importer/Distributor or Dealer____ U.S. based Exporter____ Other (Describe)_________________________Mail Order_____Yes_____NoKey Authorized VCR/Camcorder Lines_____________________________________________Key Authorized Desktop Video/Multi-Media Lines_____________________________________________BANK REFERENCESBank NameAddressTelAccount #Account #Bank NameAddressTelAccount #Account #ContactFaxType of AccountType of AccountContactFaxType of AccountType of AccountTRADE REFERENCESCompany NameAddressCityState/Prov Postal Code CountryTelFaxContact Account #Company NameAddressCityState/Prov Postal Code CountryTelFaxContact Account #
Company NameAddressCityState/Prov Postal Code CountryTelFaxContact Account #Company NameAddressCityState/Prov Postal Code CountryTelFaxContact Account #Company NameAddressCityState/Prov Postal Code CountryTelFaxContact Account #Company NameAddressCityState/Prov Postal Code CountryTelFaxContact Account #MAILING LIST ENTRIESThe following staff should receive mailings/updates: (include addresses if different)I, the undersigned, hereby warrant and represent that all information provided herein is true and accurate to the best ofmy knowledge. I authorize <strong>FutureVideo</strong> to make any and all enquiries necessary for action on this dealer application.I hereby authorize my bank and the above credit references to release information regarding my company's creditworthiness and financial condition. I also agree to abide by the provisions of <strong>FutureVideo</strong>'s Authorized Dealer or ExportProgram. I am an officer of the company.NameTitleFax or mail application form to:<strong>FutureVideo</strong><strong>FutureVideo</strong> Products, Inc.PO Box 6251Laguna Niguel, California 92607-6251 USATel: (949) 363-1286 Fax: (949) 363-9461SignatureDateApproved ByDateCLTerrFor <strong>FutureVideo</strong> Use60-02-0015
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