UA-120896936-3

Dealer Application

To become a TCK dealer, please complete the application below.

Dealer application is for new accounts only.

Business Name/DBA *

Resale Number *

Business Telephone *

Business Fax Number

Email *

Email

Confirm Email

Years in Business *

Are you a member with SAGE, ASI, or PPAI *

Yes
No

If so please enter your SAGE, ASI or PPAI number below

Sage#

ASI #

PPAI #

Number of Stores *

Estimated Sales *

Billing Address *

Street Address

Address line 2

City *

State / Province / Region *

Zip / Postal Code *

Country *

Shipping Address *

Street Address

Address line 2

City *

State / Province / Region *

Zip / Postal Code *

Country *

Owner Name *

First

Last

Owner Address *

Street Address

Address line 2

City *

State / Province / Region *

Zip / Postal Code *

Country *

Owner Phone *

Accounts Payable Contact *

First

Last

Accounts Payable Phone *

Accounts Payable Fax

Accounts Payable Email *

Email

Confirm Email

Reference 1 Name *

Street Address *

Address Line 2

City *

State / Province / Region *

Zip / Postal Code *

Country *

Reference 1 Email *

Reference 1 Phone *

Reference 1 Fax

Reference 2 Name *

Street Address *

Address Line 2

City *

State / Province / Region *

Zip / Postal Code *

Country *

Reference 2 Email *

Reference 2 Phone *

Reference 2 Fax

Reference 3 Name *

Street Address *

Street Address

Address Line 2

City *

City

State / Province / Region *

State / Province / Region

Zip / Postal Code *

Zip / Postal Code

Country *

Country

Reference 3 Email *

Reference 1 Email

Reference 3 Phone *

Reference 1 Phone

Reference 3 Fax

Reference 1 Fax

Additional Notes

Name