Dealer Application Form Company Name: Address: Address 2: City: State: Zip: Country: Airport Location: Telephone: Telephone (2): Fax: E-Mail: Website: Place on DAC’s Website: YesNo What Avionics product lines (and Categories) is your company an authorized dealer for? Primary Contact: Title & Email Address: Optional Contact: Title & Email Address: Shipping Instructions: Account Number: Shipping Address: State Resale Certificate or Sales Tax & Use Certificate: Credit Amount Requested: Terms Requested: FAA License Class: Limitations: Date Issued (mm/dd/yyyy): Please include a copy of your repair station license: Number of employees: Additional Information: Application for credit Firm Legal Name: Trade Name: Street Address: City: State: Zip: Country: Telephone: FAX: Website: Officers or Owners: Title: Persons to Contact Regarding Financial Matters & Email Address: Persons to Contact Regarding Purchasing: Avionics Manager (If Applicable) Email Address: Resale Sales Tax Number: Date Business Started: In State of: Type of Business: Credit Amount Requested from DAC Current Approved Credit Lines: Amount of Line: Current Approved Credit Lines: Amount of Line: Current Approved Credit Lines: Amount of Line: List (3) credit References - Please provide a minimum of three references that are located in the U.S.A., Avionics Related, and that will respond in a timely manner. Important - Include Fax or Email for each reference listed. Company (Name and Address): Contact Name: Fax Email Telephone: Reference 2 Company (Name and Address): Contact Name: Fax Email Telephone: Reference 3 Company (Name and Address): Contact Name: Fax Email Telephone: Bank References Bank Name: Bank Office: Address City State Zip I/We warrant the information shown above on this application to be true. I/We authorize the person to whom this application is submitted to investigate the references herein pertaining to our credit and financial responsibility.