Dealer Registration form

Role

First Name

Last Name

Username

E-mail Address

Password

Confirm Password

Billing Details

First name *

Last name *

Firm Name

Country / Region *

Street address *

Town / City *

ZIP Code *

Phone *

Email address *

Shipping Details

First name

Last name

Firm Name

Country / Region

Street address

Town / City

State / Province

Zip / Postal code

Phone

Email address

Business Information

How Long Have You Been In Business

Federal Tax ID Number

Tax Certificate

Upload

Bank Information

Bank Name

Contact Name

Bank Address

Account Number

Bank Phone Number

Major Supplier - Reference Information

Company Name 1

City And State 1

Email Address 1

Phone Number 1

Company Name 2

City And State 2

E-mail Address 2

Phone Number 2

Company Name 3

City And State 3

E-mail Address 3

Phone Number 3

Company Name 4

City And State 4

E-mail Address 4

Phone Number 4

Corporate Officers Name 1

Corporate Officer Title

Corporate Officer Residence Address

Corporate Officer Residence Phone

Corporate Officers Name 2

Title 2

Residence Address 2

Residence Phone 2

As duly authorized OwnerIOfficer of

I, the undersigned, warrant that the information herein given is correct and request that standard credit terms be extended by Thompson Trades Inc. to our company base on this information. I/We authorize Thompson, Inc to verify our credit background and further authorize our references to release information directly to Thompson, Inc_ for such verification.

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Title

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