Dealer Application
Corporate Address:
47 Mark Drive, San Rafel, CA  94903
Toll Free #: (877) 785-7666

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 415-499-9444
<< ALL SECTIONS ARE REQUIRED FIELDS>>
COMPANY INFO
Company Name:
Billing Address:
City:       State:       Zip:
 
Shipping Address (if different):
City:       State:       Zip:
 
Phone:       Fax:       Mobile:
 
Federal Tax ID #:      Business License #: 
Date Established:       Web Site:
Type Of Company:    Sole Proprietorship     Partnership     LLC     Corporation (State Incorporated: )
Principle Business Activity:    Custom Istaller      Retailer      Other
CONTACT INFO
Purchasing Contact Name:
Phone:       Email:
 
A/P Contact Name:
Phone:       Email:
 
Main Sales/Marketing Contact Name:
Phone:       Email:
We prefer to have invoices delivered via:    US Mail      Email
OWNER(S) INFORMATION
Name:      Title:
Street Address:
City:       State:       Zip:
Driver's License#:       State:
 
Name:      Title:
Street Address:
City:       State:       Zip:
Driver's License#:       State:
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 CERTIFICATEMULTIJURISDICTION

The below-listed states have indicated that this form of certificate is acceptable, subject to the following notes. The issuer and the recipient have the responsibility of determining the proper use of this certificate under applicable laws in each state, as these may change from time to time.

Issued to Seller: Electronic Stockroom, 47 Mark Drive, San Rafael, CA 94903
I certify that:
Company Name:     DBA Name:
Address:
City:       State:       Zip:
Is engaged as a registered (check all that apply):
Wholesaler      Retailer     Manufacturer    Seller (California)      Lessor (see notes)
Other 
and is registered with the below listed states and cities within which your firm would deliver purchases to us and that any such purchases are for wholesale, resale, ingredients or components of a new product or service* to be resold, leased, or rented in the normal course of business. We are in the business of wholesaling, retailing, manufacturing, leasing (renting) the following:
Description of Business:
General description of tangible property or taxable services to be purchased from the seller: Audio & Video Electronics
* Click HERE to view the instructions/notes for each state
State
State Registration, Seller's Permit, or
ID Number of Purchaser*

I further certify that if any property or service so purchased tax free is used or consumed by the firm as to make it subject to a Sales or use Tax we will pay the tax due directly to the proper taxing authority when state law so provides or inform the seller for added tax billing. This certificate shall be a part of each order which we may hereafter give to you, unless otherwise specified, and shall be valid until canceled by us in writing or revoked by the city or state.

Under penalties of perjury, my typed name below in the "Authorized Signature" box indicates that I swear or affirm that the information on this form is true and correct as to every material matter.
Authorized Signature:     (Owner, Partner or Corporate Office)
Title:      Date: