Dealer/Reseller Application
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Indicates a required field
Company Information
Legal Name
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Trade Name
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Head Office Address
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Type of Entity
Sole Proprietorship
Partnership
Corporation
Other
If other please specify
Years in Business
Date of Registration
Nature of Business
No. of Locations
No. of Employees
Sales Volume
Contact Information
Contact Name (First, Last)
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Telephone Number
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Fax Number
Email Address
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Principles
Name
Address
Name
Address
Bank References
Bank Name
Branch Number
Account Number
Bank Name
Branch Number
Account Number
Trade References
Company Name
Contact
Telephone Number
Terms
Company Name
Contact
Telephone Number
Terms
Other
Additional Comments
I/We authorize Computer Ultra to use the above information to obtain credit history/reports.
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