BLOODLINE INDUSTRIES LLC by mlw20723

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									                               BLOODLINE INDUSTRIES LLC
                                            PO Box 3203
                                         FERNDALE, WA 98248
                                             PH: (206) 501-3163
                                            FAX: (206) 299-4084
                                         tyler@themachineshop.us

                                     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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