Dealer Information Sheet

Date:______________                                                               Dealer Id #: ____________

Name of Dealership:_______________________________________________________

Street Address:     _________________________________________________________

Mailing Address: _________________________________________________________

Telephone #:     __________________________   Fax # : _________________________

Dealer License # _________________________  Expiration Date: __________________

State Sales Tax #: _________________________ Federal ID # :____________________

Bonding Company: _______________________________________________________

Bond #: ______________________________   Expiration Date:___________________

Liability Ins. Company: ___________________________________________________

Policy #:_____________________________     Expiration Date:___________________

Type of Dealership:  New ___ Used ___ Wholesale ___ Salvage ___ Lease ___

Sole Proprietorship _____   Corporation _____   Partnership _____

How long in business________________         How long at this address_______________

Owners Name:  ____________________       Owners Name:  ______________________

Home Address:  ____________________      Home Address:  ______________________

City:___________ State: ___ Zip : _____      City: ___________ State:____ Zip:_______

Home Phone #: ____________________       Home Phone #: ______________________

CELL # ____________________________  CELL # _____________________________

DOB: __________ SS #: _____________      DOB : ________ SS #: ________________

D.L. # ___________________ State:____      D.L. #: ___________________ State: ____