New Dealer Application

If you are having trouble filling this online form out, click HERE to fill out a PDF version. After it is complete, please fax it to 415-491-6210

Dealer Application
Corporate Address:
47 Mark Drive, San Rafel, CA 94903
Toll Free #: (877) 785-7666
Company Information (* = Required Fileds)
* Company Name:
* Billing Address:
* City:
* State:
* Zip:
Is the shipping address the same as above? Yes No
* Email:
Phone:
Fax:
Mobile:
* Federal Tax ID #:
* Business License #:
* Date Established:
* Website:
* Type of Company: Sole Propritorship
  Partnership
  LLC
  Corporation , State Incorporated:
   
* Principle Business Activity: Custom Installer
Retailer
Other
Owner(s) Information
* Name:
* Title:
* Street Address:
* City:
* State:
* Zip:
* Driver's License #:
* State:
* Main Contact Person Yes No
Additional Contact Information
* Name:
* Title: Purchase A/P Main Sales/Marketing
* Phone:
* Email:
We prefer to have invoices delivered via US Mail E-mail
Internet Policy (read and type your initials where required.)
I understand that I am NOT authorized to sell products via the Internet as per my dealer agreement
  (Initials Required)
Default Provisions

I agree to the terms as stated above and acknowledge all statements made herein are true and accurate to the best of my knowledge.

In the event of any breach of contract and/or default by Customer, The Electronic Stockroom shall be entitled to any and all remedies available at law or in equity. Additionally, should said breached or defaulted account be referred for collections, the undersigned customer, in addition to the amounts owing shall pay (a) the greater of the actual cost of collection or a minimum amount of twenty-five percent (25%) of the principal balance, and b) actual attorney fees and charges, if any, incurred. Customer understands that on any unpaid balance, interest shall be charged at the rate of 1.5% per month. I understand that all accounts 90 days pas due will be sent to collections. Furthermore I agree to pay any expenses incurred by Electronic Stockroom, Inc., legal or otherwise, to collect any past due amounts on my account.

* Company Name:
* Authorized Signature:
* Title:
* Date:

My/Our typed name(s) below in the "Guarantor Signature" box(es) indicate that I/We, the undersigned guarantor(s), unconditionally guarantee(s) full payment of all sums due and owing, pursuant to the terms indicated, personally and in rem. (Spouses signature required if married)

* Guarantor Signature:
* Date:
Guarantor Signature:
Date:
Uniform Sales & Use Tax Certificate Jurisdiction
* Do you plan to pay your sales tax upfront? Yes No