Dealer ApplicationPlease enable JavaScript in your browser to complete this form.Company NameAddressCity State ZipPhoneFaxEmail *CorporationLLCPartnershipSole ProprietorshipYears in BusinessContact NameReferences- Please list Name, Address, Contact, Email, Phone and Fax numbers.1.) NameAddressPhoneFaxEmail2.) NameAddressPhoneFaxEmail3.) NameAddressPhoneFaxEmail4.) NameAddressPhoneFaxEmailBank NameAcct #Address Phone #Contact NameFax #Checkboxes *I understand that my signature below constitutes permission for the bank referenced above to release credit information to Akerly & Childs Inc. upon their request. This information will be kept confidential and will be used for credit rating purposes only.Signature *Title *Date *Akerly & Childs Inc. 25008 Avenue Kearny, Valencia, CA 91355 (661)702-1909 Fax (661)702-1906Submit
