Dealer Name:   * Company     Phone   * Fax         Sole Proprietor Partnership Corporation Federal ID # State Dealer #       Seller's Permit # DEALERSHIP ADDRESS Address   *       City   * State   * Zip   *             MAILING ADDRESS Name:         Address         City State Zip DEALER VERIFICATION Owner's Name Date of Birth SS# Owner's Name Date of Birth SS# BANK AFFILIATED WITH Bonding Company Expiration Date:     Bank Account #     Bank Address City     State Zip             E-Mail