Dealer Application

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US & Canadian Applicants - Please Complete All Sections
Click Here for a Downloadable Dealer Application.
International Customers Click Here for a Downloadable Dealer Application.

Type of Credit Requested*: Credit Card PrePay w/Check NET 20 Days Open Account Status

Name Of Firm*
Street*
P.O. Box
City*
State*	Zip*
Country*
Phone*	Fax
Email*
Purchasing Name
Purchasing Phone	Fax
A/P Name
A/P Phone	Fax

Subsidiary Of
Type Of Business*
Resale/Sales Tax No.*
Social Security #	Or F.E.I.N.
Check One*: Corporation Partnership Proprietorship LLC
Website
Other Locations? Yes No If Yes, How Many?
Approximate Facility Size
# Of Years in Business*	# Of Employees
How You Heard About Us
Products of Interest

Business Operates From Own Building Office Building Home Other

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 Trade References For Which You Are A Dealer, Contractor, or Installer.

1. Company*
Address
City
State	Zip
Phone	Fax

3. Company*
Address
City
State	Zip
Phone	Fax

2. Company*
Address
City
State	Zip
Phone	Fax

4. Company*
Address
City
State	Zip
Phone	Fax

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*

* Open account privileges are pending our credit approval.

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