Authorized Dealer / Reseller Application Form

Applicant Information

First Name: *
Last Name: *
Company Name: *
DBA:
Website:
Address 1: *
Address 2:
City: *
State or Province: *
Postal Code: *
Country: *
Phone: *
Fax: *
Email Address: *
PRYME Rep:

Owner Information

 
First Name: *
Last Name: *
Address 1: *
Address 2:
City: *
State or Province: *
Postal Code: *
Country: *
Phone: *

Organization & Sales Information

Organization: *
Federal Tax ID No.: * Federal Tax Exempt No.:
Years in Business: * Number of Employees: *
Purchasing Contact: * Purchasing Phone: *
Est. Monthly Purchases: * Annual Sales: *
 
Target Markets:
(check all that apply)
 
Selling Methods:
 
Radio Brands Carried:

Online Account Information

Username: *
Password: *
Confirm Password: *

 

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Authorized Dealer / Reseller Agreement

Print Dealer Agreement