EmailMe Form - Application for Jones ® dealers & distributors

I am applying to be a/an *

H-Bar Dealer

H-Bar and Frameset Dealer

Jones Bikes Distributor

Please select the type of Jones Dealership for which you are applying.

Business Name *

DBA (if different)

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Email *

Website *

Date Business Established *

Federal Tax ID # *

Resale license /Retail # *

Insurance Provider *

Insurance Policy # *

Principal Owners *

Principal Owners Home Address

Trade References

Please provide 3 references below

Business Reference #1 *

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Account #

Business Reference #2 *

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Account #

Business Reference #3 *

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Account #

Authorization

The undersigned certifies that he/she is authorized to execute this document and that all statements are correct. Verification may be obtained from any source named in the application.

The undersigned has read and agrees to the dealer requirements.

Authorized Signer *

Title *

Date Time *

MM / DD / YYYY

Comments (optional)