Dealer Program Form - LED City Signs & Lights

Company Name*
Type Of Business*
Contact Name/ Owner’s Name*
Address*
City*
State*
ZIP code:*
Telephone*
E-mail Address (required) Website*
Shipping Address (sorry no PO Boxes):*
City*
State*
ZIP Code*
The following payment information will be kept on file to be used as a recurring authorization for Pre Pay orders:
Check one:*
- VISA
- MC
- AMEX
- DISCOVER
Card #*
Expiration Date*
Printed Name of Cardholder*
CVC Code: _*
Signature*
Business Profile (Please provide resale/ tax exemption certificate along with this application
- Partnership
- Sole Proprietor
Tax ID # or Social Security #*
Corporation Tax ID #:__*
Corporation D&B #:*
Corporation D&B #:*
Number of Employees*
Number of Locations*
Years in Business*
Number of Clients*
*
- I have read and agree with the Terms and Conditions and Privacy Policy of LED CIty.

The following payment information will be kept on file to be used as a recurring authorization for Pre Pay orders: