1300 W. Olympic Blvd. #555 Los Angeles, CA 90015

Tel: (213)389-7070   Fax: (213)389-4579

 

u Exclusive Dealership Application Form

u PERSONAL INFORMATION                                                  DATE:        .           .           .

NAME: (LAST,FRIST)

SOCIAL SECURITY NO:

ADDRESS:

CITY:

STATE:

ZIP:

TEL NO:

Dr. LICENSE NO:

u BUSINESS INFOMATION

TYPE OF BUSINESS:

NAME OF BUSINESS:

ADDRESS:

CITY:

STATE:

ZIP:

PHONE NO:

NUMBER OF YEARS THE BUSINESS WAS OPERATED:

NAME AND LOCATION OF BANK:

MAY WE CONTACT FOR REFERENCE?

uLIST 2 PERSONS WHO KNOW YOUR QUALIFICATIONS AND/OR EXPERIENCE.

    NO RELATIVE

NAME/ADDRESS/PHONE#

NAME/ADDRESS/PHONE#

Signature:______________________________________________          Date:            .            .              .

REMARK: Once the application is turned-in, it will not be returned.