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Company Name:				*
Shop Name:				*
Telephone:		*	Fax:
Email:		*	Web:
Address:		*
City:		*	State/Zip:	*

Owner/Partner/Shareholder:
Corporation:			Partnership:
Sole Proprieter:			DMV Dealer Licence:
Federal Tax ID:		*	Sales Tax ID:	*
How long have you been in business?			Number of Employees:


Primary Contacts
Sales:
Service:
Parts:

Square footage devoted to
Sales:			Service:
Parts:

What other major brands do you carry?


Bank Information
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State:			*
Zip:			*
Telephone:			*
Account:			*
	Yes, I have read the MotoFino Dealer Agreement and agree to it.