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 YUKON ADVANCED OPTICS DEALER/DISTRIBUTOR APPLICATION


I would like to become a    If you sell to end users - choose DEALER.  If you sell to Dealers ONLY - choose DISTRIBUTOR.
NAME:       TYPE:  
BILL TO:   SHIP TO:  
CITY:       CITY:     
STATE:    ZIP: STATE:    ZIP:
SALES CONTACT:   PHONE:      
ACCOUNTING CONTACT:   FAX:  
COMPANY WEBSITE   EMAIL ADDRESS:  
FEDERAL ID:   TAX ID:  
FFL # (if applicable):   PO Required:  
OFFICER/PARTNER   TITLE:  SSN:  
OFFICER/PARTNER   TITLE:  SSN:  
REQUESTED CREDIT LINE:   ANNUAL SALES:       
SALES FROM
(check all that applied):
 STORE FRONT WEB
 CATALOG SHOWS 		YEARS IN BUSINESS:    
# LOCATIONS:   # EMPLOYEES:  
BRIEFLY DESCRIBE NATURE OF YOUR BUSINESS:  

 BANK REFERENCES


BANK:    FAX:   ACCOUNT NUMBER:  
BANK OFFICER:     PHONE:    ACCOUNT TYPE:  CHECKING  SAVINGS OTHER
 LOANS:          

 TRADE REFERENCES


NAME:     CONTACT:    PHONE:    FAX:  
ADDRESS:    CITY:   STATE:    ZIP:   
NAME:    CONTACT:    PHONE:    FAX:  
ADDRESS:    CITY:    STATE:    ZIP:  
NAME:    CONTACT:    PHONE:    FAX:  
ADDRESS:    CITY:    STATE:    ZIP:  

By signing this application electronically, I do hereby grant Yukon Advanced Optics Incorporated permission to conduct inquiries to assess our firm.  In the event Yukon Advanced Optics does extend credit to us, we agree to payment in full for all goods and services received in accordance with the terms and conditions (please follow this link before signing this application).
I accept the terms and conditions. . This credit application will not be processed if this field is left blank.

Electronic Signature of Authorized Officer (type your first and last name):      
   Title:  Date:  

  

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