Dealer Registraton

1 Business Information

2 Contact Information & Agreement

Business Information
Legal Name*
First Last
DBA Name*
Phone*
Website
Billing Information*
Street Address Address Line 2 City State ZIP Code
Shipping Information
Leave Blank If Billing Address Same as Shipping Address

Street Address Address Line 2 City State ZIP Code
Type of Registration*
- Corporation
- Partnership
- LLC
- Sole Proprietor
Contractor's License Number*
License State*
State
License Type*
Date Established*
Date Format: MM slash DD slash YYYY
Number of Locations*
Number of Employees*
Your current supplier/wholesaler*
How did you hear about Automated Gate Supply ?
- Search Engine
- Social Media
- Referral
- Other
Describe your Primary Business*

Business Information