MMI - Dealer Application Phone: 480.991.8753 - Fax: 480.969.4136

Date: ___________________

Business name: ___________________________________________________  Phone No. ________________________

Address: ________________________________________________________   Fax No. __________________________

City:_______________________________________________  State / Providence:_______________________________

Zip / Postal Code: _____________________________  Email: ________________________________________________

Business Type:   Individual _____  Partnership _____  Corporation _____  Years in Business: _______

Sales Tax Exempt ID# ______________________________  Federal ID# or SS#________________________________

Owners Name: _______________________________________ Phone No. _____________________________________

Address: ___________________________________________________________________________________________

City, State, & Zip: ___________________________________________________________________________________

Description of Business: ______________________________________________________________________________

___________________________________________________________________________________________________

Bank Reference

Name:_____________________________________________  Account#: ______________________________________

Address:___________________________________________  Phone No.  ______________________________________

City, State, & Zip: ___________________________________________________________________________________

Business References

Name:_____________________________________________  Phone No. ______________________________________

Address:___________________________________________________________________________________________

City, State, & Zip: ___________________________________________________________________________________

Name:_____________________________________________  Phone No. ______________________________________

Address:___________________________________________________________________________________________

City, State, & Zip: ___________________________________________________________________________________

I authorize the above named companies to release any credit information concerning my account to Martin Manufacturing.  I also swear that all information contained herein is correct.

Signed: ________________________________________________________  Date: _____________________________

Please Do Not Write Below

Reviewed By: __________  Approval: NA ____ CA ____ CK ____  Date: ___________  Dealer # ___________________

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