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Dealer Application
(This is not a credit application)


The undersigned is authorized to prepare and submit the application on behalf of the application named in item 1 below, and certifies that all the information given is true to the best of his/her knowledge. The information will be confidential and will not be given to anybody for any purpose.


 
1. Company Info:
DBA
Address Phone Number Fax Number
City State Zip
Contact Email
Website
 
2. Type of Business:
Proprietorship Owners Name
Partnership Partners Name  
Corporation Federal Tax ID  
Date Established
Monthly Gross Sales Amount
 
3. Trade References:
Company Name Contact Account Number Phone Number
1. 
2. 
3. 
Comments

FOR CUSTOMERS SERVICE OR TO ORDER BY PHONE, PLEASE CALL
MONDAY THROUGH FRIDAY
8:30am - 5:30pm (PACIFIC TIME)

IN THE U.S 1-866-275-1RSQ(1777)
OUTSIDE THE U.S. 909-287-0609

Sincerely,
Mediasync Corp.


 
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