Collins DISH Retailer Application - Page 3

FINANCIAL INFO

FINANCIAL INFO

Collins Distribution reserves the right to conduct background checks and request a current credit report from the appropriate agencies . Under penalty of perjury , misrepresentations will be subject to immediate termination of the Retailer Agreement by Collins Distribution in its sole and absolute discretion .
BANK INFORMATION Bank Name : ______________________________________________________________________________________ Bank Fax #: __________________________ Address ( city , state , zip ): ___________________________________________________________________________________________________________________ Personal Banker ’ s Name : _________________________________________________________________ Personal Banker ’ s Phone : __________________________ Checking Account #: ___________________________________________________ Loan Account #: _____________________________________________________ I authorize this bank to provide Collins Distribution with any information requested . This information will be used solely for consideration of my company background check . Signature : _________________________________________________________________________________________________ Date : _______________________
TRADE REFERENCES Company Name # 1 : ______________________________________________________ Contact : ________________________________________________________ Address ( city , state , zip ): ___________________________________________________________________________________________________________________ Phone : __________________________ Fax : __________________________ Account Number : ______________________________________________________
Company Name # 2 : ______________________________________________________ Contact : ________________________________________________________ Address ( city , state , zip ): ___________________________________________________________________________________________________________________ Phone : __________________________ Fax : __________________________ Account Number : ______________________________________________________
Company Name # 3 : ______________________________________________________ Contact : ________________________________________________________ Address ( city , state , zip ): ___________________________________________________________________________________________________________________ Phone : __________________________ Fax : __________________________ Account Number : ______________________________________________________
To my knowledge , all of the information I have provided in this Retailer Application is true and accurate .
Signature : ___________________________________________________________ Title :______________________________________ Date : _________________ Printed : ________________________________________________________________________________________________________________________________
SALES TAX RULES AND REGULATIONS - RESALE CERTIFICATE FORM This tax may not be applicable to you , but it is required of us by the State . Your cooperation is appreciated . Please attach a copy of your valid State Seller ’ s Permit . Company Name ( Proper Legal Name , Including DBA ’ s and / or Tradestyles ): ____________________________________________________________________________ Address ( city , state , zip ): ____________________________________________________________________________________________________________________ Phone : __________________________ Has your address recently changed ? Yes _ No __ If yes , when ? _______________________________________________
I hereby certify , that I hold a valid State Seller ’ s Permit ( permit #__________________________) issued pursuant to the Sales and Use Tax Law ; that I am engaged in the business of selling Direct-To-Home Satellite TV and / or Home Security Equipment and that the tangible personal property described herein which I shall purchase from Collins Distribution will be resold by me in the form of tangible personal property provided ; however , that in the event any of such property is used for purposes other than retention , demonstration or display while holding it for sale in the regular course of business , it is understood that I am required by the Sales and Use Tax Law to report and pay for the tax , measured by the purchase price of such property . Description of property to be purchased : Direct-To-Home Satellite Television and / or Home Security Equipment . Such certificate is good until revoked in writing .
Signature : ___________________________________________________________ Title :______________________________________ Date : ________________
DUNN & BRADSTREET Dunn & Bradstreet # ( if available ): _____________________________________________________
For questions call Collins Distribution at ( 800 ) 825-1100 3