Dealer Application

Name of Business (required)

DBA (required)

Address:

Address (required)

Address 2

City (required)

State (required)

Zip Code (required)

Billing Address:

Address (required)

Address 2

City (required)

State (required)

Zip Code (required)

Business Information:

Company Phone (required)

Fax (required)

Years In Business(required)

List of insurance you accept (required)

Website URL

Email (required)

Type of Business (required) CorporatePartnershipSole ProprietorshipIndividual

Principle Owner/s - Name/s, Addresses and percentage of ownership (required)

Name of parent company (if applicable)

Accounts Payable Contact Name (required)

Accounts Payable Phone (required)

Trade References (Listing 3 references is required)

List the regions you serve (required)

Contact Full Name (required)

Contact Phone (required)

Authorization

The information above is given for the purpose of establishing eligibility for a credit account with Mobility Unlimited, Inc.

Mobility Unlimited, Inc. is hereby authorized to make any credit inquiries for approval. I certify that all of the information above is correct and that I have the authority to incur liabilities and enter into this agreement in the name of the company.

Applicant Full Name (required)

First Name

Middle Name

Last Name

Applicant Company Title

Date (required)

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By clicking the Submit Form button the applicant agrees all information is true and accurate and authorizes submission.

Dealers Application