Dealer Application

Company Name: Date:
Shipping Address: Street:
  City: State: Zip:
Billing Address: Street:
  City: State: Zip:
Airport: Name: Identifier:
Contact Info: Phone: Fax:
  Accounting: Avionics Mgr:
  Email:
  Web Address:
Terms Desired: Net 15* COD (*Your 1st shipment will be COD)
  Federal ID #: (*Please include copy of Fed ID Certificate)
  Tax Resale #: (*Please include copy of Resale Tax Certificate)
FAA: Air Agency Certificate #: (*Please include copy of Repair Station Cert.)
  Repair Station Ratings: Class 1
Class 1
Class 2
Class 3

Limited/Other
Other: AEA Member: Yes No
  Shop Labor Rates: Install Bench
  Year Business Started: No. Employees:
Business Activities:
Avionics Install Avionics Repair OEM Airline
Military/Gov FBO Piston Turbine
Helicopter Homebuilt Own 4+ Aircraft
Warbirds Corporate Jets

Trade 1: Company Name: Contact:
  Street:
  City: State: Zip:
  Phone: Fax:    
  Acc #:        

Trade 2: Company Name: Contact:
  Street:
  City: State: Zip:
  Phone: Fax:    
  Acc #:        

Trade 3: Company Name: Contact:
  Street:
  City: State: Zip:
  Phone: Fax:    
  Acc #:        

Trade 4: Company Name: Contact:
  Street:
  City: State: Zip:
  Phone: Fax:    
  Acc #:        

Bank:  
Branch Name:
Point of Contact:
Street:
  City: State: Zip:
  Phone: Fax:    
  Acc #:        
D&B Registry Number: