Complete attached .DOC file and email to: suzie.hagerty@blucollarmusic.com

BCM Dealer Application

or

Print the following page and fax to: 415-230-2725

Store information:

Store Name: _________________________________________________

Address: ____________________________________________________

Address: ____________________________________________________

City:_________________________________State_______Zip _________

Phone: (___) __________-________________Extension#______________

Ship to: ❐ same

Name: _____________________________________________________

Address: ____________________________________________________

Address: ____________________________________________________

City:___________________________State_______Zip _______________

Fax # ❐ same as phone: (___) _________-____________________________

E mail ____________________________ @ ________________________

Website: _____________________________________________________

Buyer (❐ Mr. ❐ Ms. ❐ Mrs.)_____________________ ___________________

Others Authorized for Purchasing: ____________________________________

First Name ___________________Last Name_________________________

❐ Multiple Stores – # of Stores____ Central Purchasing ❐ Yes ❐ No 1.___________________________________________________________

Phone (_________) _____________________________________________

2.___________________________________________________________

Phone (_________) _____________________________________________

Bank References: Name on Account ❐ same ____________________________________________________________

Bank_________________________________________________________

Address or Branch _______________________________________________

Account # _____________________________________________________

Phone (___) ________ -_____________ Contact:_______________________

 

 

 

Business License or Resale License

(IMPORTANT: California requires a signed Tax Exemption Certificate and must be on file prior to shipping orders)

State:____________  ID#_________________________________________

Type of Store: check all that apply: ❐ Retail Music Store ❐ Pawn & Music ❐ Internet Sales Only ❐ Internet and Retail Products/Services offered: ❐ Fretted Instruments/ Amplifiers ❐ Drums/Percussion ❐ Band/Orchestra ❐ Print Music ❐ Repairs
❐ Recording Studio ❐ Keyboard/Piano/Organ ❐ Teaching Studio ❐ Spanish/Hispanic Market or Customer Base ❐ Other_____________

Store Hours: ❐ Monday to Friday from______to _______ Closed_________
Do you give lessons? ❐ Yes ❐ No

Instruments Taught: ❐ Guitar ❐ Banjo ❐ Mandolin ❐ Drums Number of Instructors: ____

Lines carried:_______________________, ___________________________.

______________________, ______________________,_______________

*I hereby certify the above information is correct and authorize above references to release any and all information concerning my account.

Print Name:___________________________________________

Signature __________________________________________Date __/___/___

Shipping: ❐ UPS ❐ other _____________

Terms: ❐ Bank Card (Visa, MC or Discover)

❐ COD Company Check (bank info required for COD)

Trade References:

Application Received Date: ____/___/__ ❐ References Checked

❐ Cat/Flyer Sent _____/_____

❐ Contacted by _____ Order Placed: ___/___/___

Account Number:_____________Date Entered: ____/____/____

Account assigned to:_________________

Notes:_________________________________________________________

______________________________________________________________

Email to: info@blucollarmusic.com