.

U.S.A. Toll Free 1-800-325-3914       Local & International 636-931-3200
Nationwide Fax 1-800-328-RIDE (7433)       International FAX 636-931-3300

.

.

.

2100 Highway Z    P.O. Box 669      Pevely, MO 63070  •  midwest@midwestmc.net

DEALERSHIP APPLICATION

New customer terms will be CASHIERS CHECK until this application has been processed.
This form must be filled out completely, legibly, and SIGNED (required; see reverse side), for Midwest Motorcycle Supply to process information.
See reverse side for open credit application. Please enclose all of the following:
1. A copy of your letterhead, business card, etc.
2. A copy of your sales tax exemption certificate.
3. A copy of your retail seller’s permit, city or county business registration.
4. Your yellow page listing under “Motorcycles”
5. Photographs of your business (inside and out). BUSINESS MUST BE SEPARATE FROM YOUR RESIDENCE.

BUSINESS INFORMATION:
Legal Firm Name
Doing Business As
Street Address
City, State, Zip CodeBilling Address
Business Phone (              )Business Fax (              )Email Address
Date Business Started

How Long Business In Present Location

Name Of Owner, Partner X

Social Security #Home Phone #Name Of Owner, Partner

Social Security #Home Phone #Home Address X

CityStateZip

Home Address

CityStateZip

Email AddressPartnershipState Where IncorporatedCorporation

Individual Partnership

Date Of Incorporation

Federal ID#Sales Tax#

PLEASE CHECK ALL THAT APPLY TO YOUR BUSINESS:
Motorcycle Franchise  n                                         Retail Chain Or Discount Store  n                    Custom Motorcycles  nH-D®#

Motorcycles Service Only  nParts & Accessories Only  nOtherTypes

DEALERSHIP VERIFICATIONTO PROTECT OUR DEALERS FROM ABUSE BY PRIVATE INDIVIDUALS OR OTHER TRADES POSING AS MOTORCYCLE DEALERS, WEDO BUSINESS ONLY WITH LEGITIMATE MOTORCYCLE DEALERS HAVING A PLACE OF BUSINESS LOCATED SEPARATELY FROM YOURRESIDENCE, BUSINESS TELEPHONE LISTED IN THE YELLOW PAGES, CURRENT EXEMPTION CERTIFICATE, AND BUSINESS LICENSE WHEREAPPLICABLE.

CREDITTO ACCEPT A COMPANY CHECK FOR PAYMENT IS CONSIDERED AN EXTENSION OF CREDIT. TO APPLY FOR C.O.D. COMPANY OR OPENACCOUNT, PLEASE PROVIDE THE FOLLOWING INFORMATION (BACK SIDE ALSO). ORDERS WILL BE SHIPPED C.O.D. CASH UNTIL CREDIT ISESTABLISHED. PLEASE ALLOW 3-4 WEEKS FOR PROCESSING.
C.O.D. CashC.O.D. Company Check

Open Account (NET 10th)

MasterCard

VISA

Discover/NOVUS

Wire Transfer

THIS AUTHORIZES THE USE OF MY MASTERCARD / VISA / DISCOVER / NOVUS (circle one) BY MIDWEST MOTORCYCLE SUPPLY DIST. CORP.
TO PAY FOR ORDERS PLACED BY PHONE.
My MasterCard / VISA / Discover / NOVUS (circle one) number is:
Expiration Date                3 Digit CVC #:Cardholder’s Name (please print)

Billing Address      Billing Zip CodeSignature

Date

PLEASE FILL OUT COMPLETELY TO APPLY FOR C.O.D. COMPANY CHECK OR OPEN ACCOUNTBank Name

Account #Address

Bank Phone # (              )City, State, Zip Code
LIST REFERENCES WHICH ACCEPT YOUR COMPANY CHECK OR EXTEND CREDIT ON ACCOUNT (PREFERABLY WITHIN THE MOTORCYCLE
INDUSTRY).  DO NOT LIST MIDWEST MOTORCYCLE AS A REFERENCE.
Name

Dealer Account #Address

Phone # (              )City, State, Zip CodeContact

Terms With Company:n  Openn  C.O.D.

n  Company Checkn  Cashn  Other

Name

Dealer Account #Address

Phone # (              )City, State, Zip CodeContact

Terms With Company:n  Openn  C.O.D.

n  Company Checkn  Cashn  OtherNameDealer Account #Address

Phone # (              )City, State, Zip CodeContactTerms With Company:n  Openn  C.O.D.

n  Company Checkn  Cashn  OtherI AM APPLYING FOR COMPANY CHECK ACCEPTANCE/OPEN ACCOUNT FROM MIDWEST MOTORCYCLE. PLEASE RELEASE THEINFORMATION NEEDED TO HELP THEM MAKE THEIR DETERMINATION. I HAVE COMPLETED THIS APPLICATION TO OBTAIN CREDIT. I CERTIFYTHAT THE STATEMENTS ABOVE ARE TRUE.
I AUTHORIZE MIDWEST MOTORCYCLE TO CHECK ALL INFORMATION LISTED.  THE USE OF MY CORPORATE TITLE IS ONLY TOIDENTIFY MY POSITION IN THE COMPANY AND IN NO WAY NEGATES MY PERSONAL GUARANTEE.  I PERSONALLY GUARANTEEPAYMENT OF ALL MONIES DUE AND OWING, INCLUDING COLLECTION FEES AND/OR ATTORNEY FEES AND COURT COSTS TO MIDWEST
MOTORCYCLE FOR PURCHASES MADE IN THE EVENT
DOES NOT PAY THE AMOUNT

Owner’s Printed Name

Date

Owner’s signature
If more than one owner, second must both print and sign copy of this form

Date

8MCompany Name (Print)