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New Account

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.

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