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WIRELESS
TOW LIGHTS, INC. DEALER APPLICATION
We welcome dealer inquiries. Please print this form, complete and fax to us at 806-748-0676. COMPANY NAME
_________________________________________________________________________________ TYPE OF BUS.
_________________________________________________________________________________ ___ Individual
___ Partnership ___ Corporation SHIPPING ADDRESS ________________________________________________________________________ CITY _____________________________________ STATE _______________ ZIP__________________________ BILLING
ADDRESS________________________________________________________________________________ CITY
____________________________________ STATE ____________________ ZIP ________________________ PHONE ________________________________________FAX____________________________________ STATE
SALES TAX PERMIT NO. (REQUIRED)____________________________________________________________ DIR/PR0PRIETOR_________________________________________________________________________________ ORDER CONTACT_________________________________________________________________________________ EMAIL ADDRESS
_____________________________________
CELL PHONE ________________________________ Number of years in business? ________ Storefront business? ______yes ______no How Many Locations?
___________
BANK REFERENCE Bank Name
_______________________________________________________________________________________ Address _______________________________________________________________________________________ City
__________________________________________________State_______________
Zip______________ Phone
__________________________________________________ Fax
_________________________________ Contact
_______________________________________________________________________________________ CREDIT CARD INFORMATION: VISA MASTERCARD DISCOVER CARD NUMBER ___________ ____________ ____________
___________ EXP DATE
______/_______________ 3 DIGIT #
____________ NAME OF
CARD___________________________________________________________________________________ BILLING ADDRESS
FOR CARD ________________________________________________________________________ SIGNATURE ___________________________________________________________
DATE ______________________ Wireless
Tow Lights, Inc.
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