Mailing Address: _________________________________________________________

City: _______________          State: _______ Zip Code: _____________________

Phone NO: __________________________  Fax NO: ____________________________

Email Address: ___________________________________________________________

Website: ________________________________________________________________

Shipping Address (If other than Mailing): ______________________________________

City: _______________          State: _______ Zip Code: _____________________

Phone NO: __________________________  Fax NO: ____________________________

Business Type:        Proprietorship____ Incorporated _____ Partnership ____

In business since: ___________________ Present Owner Since: ____________________

Federal I.D.# ______________________ State Resale # __________________________

Owned By: ______________________________________________________________ 

Accounts Payable contact: _________________ Phone NO: _______________________

Primary contact: _________________________ Phone NO:_______________________

Technical Support Contact: _________________ Phone NO: ______________________

Owner’s Home Address: ___________________________________________________

City: ________ State: ___ Zip Code: ______ Home Phone NO: ____________________

Main Brands Carried:

Principal bike brands by % carried: __________________________________________

Bike frame brands by % carried: ____________________________________________

Shoe brands by % carried:   ________________________________________________

Clothing brands by % carried: ______________________________________________

Helmet brands by % carried: _______________________________________________

Credit References:

            Name & Address                             Phone NO                           Fax NO

1. ______________________________________________________________________

2. ______________________________________________________________________

3. ______________________________________________________________________

Bank and Credit Card Authorization

Bank Name: _______________________ City: ________________ State: ___________

Phone NO: _________________________    Fax NO: ____________________________

Account #: Checking____________________               Saving ______________________

Store Credit Card # ________________________________ Name on card: ___________

Exp. Date: ________ Credit Card mailing addressee Street# ________ Zip Code: ______

            You are hereby authorized to release information on all our accounts maintained at our bank to TRIALTIR U.S.A. INC. including average balance, activity, and NSF history.
            You are hereby authorized to charge on our credit card for the balance on our account over 60 days from invoice due date and mail either our account statement or invoices with credit card receipt to us.
            The information given in this application is complete and accurate, and authorizes TRIALTIR U.S.A. to check with credit reporting agencies, credit references, banks, and other sources disclosed herein in investigating the information given.

DATE: _____________          _______________________     _____________________
                                                                    (Authorized Signature)                    (Authorized Print Name)