BLOODLINE INDUSTRIES LLC PO Box 3203 FERNDALE, WA 98248 PH: (206) 501-3163 FAX: (206) 299-4084 email@example.com DEALER APPLICATION BUSINESS INFORMATION BUSINESS NAME: BILLING ADDRESS: CITY/STATE/ZIP CODE: PHONE#: FAX#: COMPANY WEBSITE: EMAIL ADDRESS: SHIPPING ADDRESS: (Leave blank if same as billing info): CITY/STATE/ZIP CODE: FEDERAL TAX ID#: STATE RESALE#: DATE BUSINESS OPENED: TRADE REFERENCES COMPANY NAME: CONTACT: PHONE#: FAX#: COMPANY NAME: CONTACT: PHONE#: FAX#: COMPANY NAME: CONTACT: PHONE#: FAX#: TERMS/AGREEMENT Current terms are prepaid via credit card, COD, or advance payment by check. Any company checks returned to Bloodline Industries LLC will be subject to a $30.00 returned check fee. Dealer agrees to the terms and that all information given above is correct. SIGNED: DATE: PRINT NAME: TITLE: PLEASE FAX BACK THIS FORM ALONG WITH COPIES OF YOUR BUSINESS LICENSE AND SALES TAX PERMIT.
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