Please print this page and fax to 509.277.7169 USA
or +1.416.352.5569 CANADA/International
 Please attach: Business Card & Government Issued Business License

We will reply by fax ASAP after receiving your application with information about your approval.

Business Info:
Business Name:
Address:
 
City, State, Zip, Country:
Phone Number:
Fax Number (required):
Email Address:
Web Site:
Tier level Request:

Based on the tier levels described on www.bimmianwholesale.com please choose which tier level you would like to apply for.  Please note that some tier levels require up-front payments to secure higher discount levels.

(  )    Tier X: Volume Stocking Dealer - No Charge

(  )    Tier 1: New Reseller - No Charge

(  )    Tier 2: Occasional Reseller - $150 charge

(  )    Tier 3: Consistent Reseller - $500 charge

(  )    Tier 4: Dedicated Reseller - $1,000 charge
 
Proprietors Info:
Your Name (first and last required):
Your Position:
Products Of Interest:








 
Brands Of Vehicles Targeted:
 
Please Tell Us About Your Business:

Years In Business:
 

Corporation / Partnership / Proprietorship (Circle One)
 

Home Based / Garage / Warehouse / Storefront / Mall     (Circle as many as apply)
 

Retail / Mail-Order / Distributor / Warehouse       (Circle as many as apply)
 

Do you sell online and accept PayPal from your customers?    YES   /   NO
 
Other Products Carried:









 
How would you like to sell our products:

(  )    Order in bulk and stock our products at your location

(  )    Order As-Needed + samples stocked - customers see samples before buying
         Items are delivered to your location for customer pickup / installation

(  )    Order As-Needed, customer gets product info from print / web
         Items are delivered to your location for customer pickup / installation

(  )    Order from us as customers order from you - we ship directly to your customer
 
Please Tell Us About Your First Order:

(  )    Will Order Immediately

(  )    Want to be set up for use in the future
 

Estimated Order Value:

Products In First Order:

 
Trade References:

Please list three other sources you are using to buy the products you currently resell:

Name 1: ______________________________________________

Phone/Web:  ______________________________________________

 

Name 2: ______________________________________________

Phone/Web:  ______________________________________________

 

Name 3: ______________________________________________

Phone/Web:  ______________________________________________