Collins DISH Retailer Application - Page 2

COMPANY PROFILE

COMPANY PROFILE

COMPANY INFORMATION Company Name : __________________________________________________________ Website : ______________________________________________________ Address ( city , state , zip ): ___________________________________________________________________________________________________________________ Principal Contact : __________________________________________________________ E-mail : _______________________________________________________ Phone : Work __________________________ Cell __________________________ Home __________________________ Fax __________________________ Type of Ownership : Sole Proprietor ___ C Corp ___ S Corp ___ All Other LLCS — Specify _______________ Partnership ___ Trust / Estate ___ Other _______________ Federal Tax ID #: _________________________________ How long in business : _______ Years _______ Months Annual Sales Volume : $ ______________
SHIP TO ADDRESS ( if different than above ): Address ( city , state , zip ): ___________________________________________________________________________________________________________________
ADDITIONAL BUSINESS LOCATIONS Company Name : _________________________________________________________________________________________________________________________ Retailer Name : ___________________________________________________________________________________________________________________________ # 1 Address ( city , state , zip ): _________________________________________________________________________________________________________________ # 2 Address ( city , state , zip ): _________________________________________________________________________________________________________________ Principal Contact : _________________________________________________________________________________________________________________________ E-mail : _______________________________________________________________ Phone : __________________________ Fax : __________________________ PRINCIPALS , PARTNERS or OFFICERS Name # 1 : _______________________________________________________________ Title : _________________________________________________________ % of Ownership : _________ Social Security #: ____________________________________________________ Are you a U . S . citizen ? Yes _ No ________ Home Address ( city , state , zip ): ______________________________________________________________________________________________________________ # 1 Phone : __________________________ # 2 Phone : __________________________ E-mail : _______________________________________________________
Name # 2 : _______________________________________________________________ Title : _________________________________________________________ % of Ownership : _________ Social Security #: ____________________________________________________ Are you a U . S . citizen ? Yes _ No ___ Home Address ( city , state , zip ): ______________________________________________________________________________________________________________ # 1 Phone : __________________________ # 2 Phone : __________________________ E-mail : _______________________________________________________
Name # 3 : _______________________________________________________________ Title : _________________________________________________________ % of Ownership : _________ Social Security #: ____________________________________________________ Are you a U . S . citizen ? Yes _ No Home Address ( city , state , zip ): ______________________________________________________________________________________________________________ # 1 Phone : __________________________ # 2 Phone : __________________________ E-mail : _______________________________________________________
COMPANY HISTORY Has the Company , any Principal , Partner or Officer ever filed for bankruptcy ? Yes _ No _ If yes , when ? __________________________________________________ Has the Company , any Principal , Partner or Officer ever been convicted of a felony ? Yes _ No __ If yes , when and what ? _____________________________________ Has the Company , any Principal , Partner , or Officer ever conducted business with Collins Distribution ( aka CVS Systems ) under a different business name , or under any name that was / is considered “ out of business ”? Yes _ No __ If yes , who ? __________________________________________________________________________ Has the Company , any Principal , Partner or Officer purchased DISH equipment from an Authorized DISH Distributor other than Collins Distribution ( aka CVS Systems )?
Yes _ No __ If yes , what was your OE #? _______________ Who was the Distributor ? _____________________________________________________________ How did you hear about Collins Distribution ? ____________________________________________________________________________________________________ Are you currently operating a business full time ? Yes _ No _____ Have you ever sold or installed satellite TV and / or home security systems ? Yes _ No _ If yes , what was the name of the company ( s ) or person ( s ) for which you sold and / or installed ? __________________________________________________________________________________________________________________________ If you were you a subcontractor , for what company or person did you last work ? Name : _____________________________________ Phone : _____________________
2 www . CollinsDistribution . com