Dealer Application

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Dealer Information

Dealer Name:
Owner:
Business Type:
Business Address
Business Address:
City:
State/Province:
Zip/Postal Code:
Country:
Mailing Address
Same as Business:
Mailing Address:
City:
State:
Zip/Postal Code:
Country:

Phone:
Fax:

Primary Contact

	Position	Name	Email

Additional Personnel

	Position	Name	Email

Add Personnel

Annual Sales Volume

Residential:
Non-Residential:
Rental:
Used:
Parts & Service:
Total Sales Volume:	$0.00

Association Memberships

Member Of

Add Association (Choose all that apply)

Major Lines

Major Line

Add Major Line (Choose all that apply)

Units Sold

	Unit Type	Number Sold

Add Unit (Choose all that apply)

Shop Labor Rates

Residential:	/hr Please enter a value
Non-Residential:	/hr Please enter a value

Agreement

By entering your full name you are electronically signing this document stating that you have read and agree with the terms and conditions created therein and that you are authorized to sign binding documents on behalf of your company..

Signature:	Enter Your Full Name

Up to 5 years total equipment protection.

FAIL-SAFE has been offering BULLET-PROOF PROTECTION against unexpected mechanical breakdowns since 1987.