AyersWireless Dealer Application

DEALER APPLICATION

Dealer requirements:

Each dealer must have a social security or tax ID number
All monthly payments for your site will be charged to your credit card automatically

Complete the following application for your own wireless accessories online store:

Company Name:
Address 1:
Address 2:
City:
State:
Zip:
Phone:
Fax:
Order Notification Email Address:
Who will be the primary contact:
Last Name:
First Name:
Address 1:
Address 2:
City:
State:
Zip:
Phone:
Email:
Site information:
Do you already have a domain name:	If no, supply five choices
Existing Domain Name or First choice:
Second choice:
Third choice:
Forth choice:
Fifth choice:
Do you have a company logo:
Information you want on the "About Us" page:
Information you want on the "Contact Us" page:
Payment information:
You may pay now or wait until contacted to set up your site.
Payment method:
Card Number:
Name on Card:
Expiration:
Referral Code (if any):