Dealer Application

Page 1



















Address



Ex.Massachusetts






Contacts
Contact 1 - Purchasing




Contact 2 - Payables




Contact 3 - Sales Manager/Other




Company Ownership/Officers
First Officer/Owner/Principal
Note: The email address entered here will receive an email for electronic signature via DocuSign.







Second Officer/Owner/Principal
Note: The email address entered here will NOT receive an email for electronic signature via DocuSign.







Requested Terms:






Trade References:
Please fill out trade references completely;  missing information will delay the processing of your application. Email speeds up response.
Trade Reference 1





Trade Reference 2





Trade Reference 3





Trade Reference 4





The information provided is supplied with the intention of becoming an authorized reseller, and I do hereby certify that this information is true, correct, current and complete. I authorize Starin Marketing, Inc. to make such credit investigation as Starin Marketing, Inc. sees fit, including information concerning the financial and credit history of my company and myself:
I hereby agree to the terms and conditions listed on the attached page.

We need the following information to complete your Form ST105

SECTION 1

Instructions to complete the section

A)  This section requires an identification number. In most cases this number will be an Indiana                        Department  of Revenue issued Taxpayer Identification Number (TID - see note below) used for                    Indiana  sales  and/or withholding tax reporting. If the purchaser is from another state and does not            possess an Indiana TID Number, a resident state’s business license, or State issued ID Number must be        provided.

B) Exceptions - For a purchaser not possessing either an Indiana TID Number or another State ID                       Number,  the following may be used in lieu of this requirement.
     Federal Government – place your FID Number in the State ID Number space.
     Farmer – place your SSN or FID Number in the State ID Number space.
     Public transportation haulers operating under another motor carrier authority, or with a contract as a         school bus operator, must indicate their SSN or FID Number in the State ID Number space.
     Nonprofit Organization – must show its FID Number in the State ID Number space.
Provide your Indiana Registered Retail Merchant’s Certificate TID and LOC Number as shown on your Certificate.

If not registered with the Indiana DOR, provide your State Tax ID Number from another State
*See instructions on the reverse side if you do not have either number.

SECTION 2

Instructions to complete the section

A) Purchaser must check the reason for exemption.
B) Purchaser must be able to provide additional information if requested.

Purchaser must indicate the type of exemption being claimed for this purchase. (check one or explain)
Sales to a retailer, wholesaler, or manufacturer for resale only