Dealer Application

* = Required

Dealer Information

Business Address

Mailing Address

Primary Contact

Position Name Email

Additional Personnel

Position Name Email

Annual Sales Volume

$0.00

Association Memberships

Member Of
Add Association (Choose all that apply)

Major Lines

Major Line
Add Major Line (Choose all that apply)

Units Sold

Unit Type Number Sold
Add Unit (Choose all that apply)

Shop Labor Rates

/hr
/hr

Agreement



By entering your full name you are electronically signing this document stating that you have read and agree with the terms and conditions created therein and that you are authorized to sign binding documents on behalf of your company.

Enter Your Full Name

Upon meeting the criteria to become a Midwest Administrative Services Dealer, you will be invoiced a $150.00 Dealer Setup Fee. See Apply to Become a Midwest Administrative Services Dealer, item 4, for details.