Dealer Application

Dealer Login:			Password:
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Please Complete All Sections Click Here for a Downloadable Dealer Application.

Type of Credit Requested*: Credit Card C.O.D. Company Check NET 20 Days Open Account Status

Name Of Firm*	Subsidiary Of
Street*	Type Of Business*
P.O. Box	Resale/Sales Tax No.*
City* State* Zip*	SS# Or F.E.I.N.
Country*	DUNS#
Phone* Fax	Check One*: Corporation Partnership Proprietorship
Email*
Purchasing Name	A/P Name
Purchasing Phone Fax	A/P Phone Fax
# Of Years in Business* # Of Employees	Do You Have Service Facilities? Yes No
Approximate Facility Size	Other Locations? Yes No If Yes, How Many?
Year Established*
Business Operates From Own Building Office Building Home Other
What TecNec Products Are You Interested In?

Current Industry Membership (check all that apply): NAB SMPTE ITVA SBE AES NSCA NAMM CEDIA Other

Although I have provided my e-mail and fax number, I do not wish to receive promotional faxes and e-mail sent by TecNec.

Please List Four Manufacturers For Which You Are A Dealer, Contractor, or Installer.

1. Company*	2. Company*
Address	Address
City State Zip	City State Zip
Phone Fax	Phone Fax
Doing Business Since	Doing Business Since
3. Company	4. Company
Address	Address
City State Zip	City State Zip
Phone Fax	Phone Fax
Doing Business Since	Doing Business Since


Please fax a Signed Certificate of Resale to 845-246-0626 so that we can process your application.

I certify that all statements made by me in this application are correct to my knowledge. I authorize Tower Products to investigate and verify the information I have provided herein.
Your name* Title* Date*

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