Accessories Unlimited South

Accessories Unlimited South

Chrome Billet Headlights Manufacturer

New Dealer Application
Please fill out the form below with as much information as possible and a Accessories Unlimited South representative will contact you. You may also print this form and fax it to 888-833-6045. Fields with an (*) are required.

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Company Name:    
Billing Address:    
City:    
State:    
Zip:    
Phone:    
Fax:    
Contact Name:    
Email:     * required
Type of Business:    
Website Address:     (if applicable)
Sales Tax ID:    
How long have you been in business:    
Shipping Address:   Same as Billing      Different from Billing

If your Shipping Address is different from above, please fill in the fields below.
Shipping Address:    
Shipping City:    
Shipping State:    
Shipping Zip:    
       

Specializing in:

   (check all that apply)  
    New Bike Sales Used Bike Sales  
    Parts Accessories  
    Custom Bikes Service  
Names of employees authorized to place orders for your company   
First Employee:      
Second Employee:      
Third Employee:      
Fourth Employee:      
Fifth Employee:      
Do you use Purchase Orders:   Yes No  
How did you hear about Accessories Unlimited:      
Would you like to be contacted regarding special promotions:   Yes No  
Payment Terms:  All new accounts shall pay by Credit Card (MC, VISA, AMEX, DISC) or COD Money Order (A UPS COD charge of $8.50 per package will be added to your order). If you wish to pay by COD Company Check, please complete the following for application.

Trade References
Company Name:     Phone:  
Address:     Open Account: Yes No
Company Name:     Phone:  
Address:     Open Account: Yes No
Company Name:     Phone:  
Address:     Open Account: Yes No
Bank Name:     Phone:  
Address:     Account Number:  

By submitting this application, I authorize Accessories Unlimited South, Inc. to make inquiries to the banking, business and/or trade references I have supplied.
     

Signature: 

Title:  Date:  (ex: 01-12-2007)

(if submitting electronically, type name)

    

Comments or Questions:

 
 
Accessories Unlimited South, Inc. respects your privacy. No information submitted will be sold or used for any other purpose.

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