Dealer/Credit Application

Thank you for your interest in First Gear and William Britain product lines. If you wish to be considered as a dealer for either or both lines, please complete the following Dealer Application. Completion of this form should precede your initial order so as to allow time for a proper evaluation of your Application.

The information you provide will be kept confidential.

Company Information
Company Name:
Contact Name:
Street Address:
City:		State:		Zip Code:
Country:
Business Phone:		Cell Phone:		Fax:
Website Address:			E-mail Address:
Type of Business: (Check all that apply)	Store Front Online (Website) Auction-Based Other:			Years in Business:
Types of product you currently sell:
What is your annual volume of sales?
Which product line are you interested in? First Gear William Britain Both
Credit Line Requested:		Federal Tax ID #:

Has applicant ever filed for relief under Bankruptcy or Receivership? No Yes

Are there any suits or unsatisfied judgments against Applicant? No Yes

Owners/Partners/Principals
Name	Title	Telephone

Bank References
Bank Name:
Address:
Account Number(s) and Type of Account:		Contact Name:
Phone:		Fax:
Financial Statement Available? Will Send Will Not Send

Bank Name:
Address:
Account Number(s) and Type of Account:		Contact Name:
Phone:		Fax:
Financial Statement Available? Will Send Will Not Send

Trade References
List three trade suppliers from whom you buy on open account.
Company Name:
Street Address:
City:	State:		Zip Code:
Telephone:		Fax:

Company Name:
Street Address:
City:	State:		Zip Code:
Telephone:		Fax:

Company Name:
Street Address:
City:	State:		Zip Code:
Telephone:		Fax:

By completing this form the undersigned Applicant hereby agrees to all Terms and Conditions stated or implied.

Terms and Conditions:

1. On all accounts past due 1½% INTEREST PER MONTH (18% ANNUAL PERCENTAGE RATE) will be charged.
2. Should it be necessary to assign the account balance to a licensed collection agency or attorney for legal action, all subsequent collection charges and legal fees shall be paid by the applicant
3. The undersigned agrees to the terms and conditions herein.
4. The above supplier(s) and/or bank(s) are hereby authorized to release information pertinent to a credit check to First Gear.
5.This application may be reproduced to provide or obtain such authorizations.

Please be assured that all information provided will be held confidential.

Signature:
Date: February 04, 2012