DEALER ENROLLMENT FORM  

*Required fields

Company Information
* Legal Company Name:   Trade/DBA Name:  
* Physical Address:  
*City:
* State: *Zip:
*Date Business Started:
*Federal ID #:
*Primary Contact:   Type of Business:
*Office Phone:
Cell Phone:
*Email:  
*Number of Employees:   *Number of Sales Reps: 
* Total Annual Sales Volume:   Website: 
   
HVAC CONTRACTORS ONLY
Contractor License:
Residential Sales Volume:  Avg. Installs/Month: Active Maintenance Contracts:
Commercial Sales Volume:  Avg. Installs/Month: Active Maintenance Contracts:
   
How were you referred to Horizon Keystone?
*  Individual Name: * Company:
   
Payment Information
* Payment Preference:   (If ACH or Wire, complete below)
Bank:   Account#:
ABA#:   Name on Acct:
Standard Terms:   A/R Invoice Contact:
   
References
* Manufacturer/Distributor:   * Lead Line/Brand Sold:
* Contact:   * Phone #:
Terms:     Date of last purchase:
E-Mail:
* Manufacturer/Distributor:   * Lead Line/Brand Sold:
* Contact:   * Phone #:
Terms:     Date of last purchase:
E-Mail:
   
Ownership
* First Name:   * Last Name:
* Title: * Ownership %:
Home Phone #: Cell Phone #:
 
Ownership
First Name:   Last Name:
Title: Ownership %:
Home Phone #: Cell Phone #:
 
Other Information
*Horizon Keystone Consultant:
* Do you want training on how to offer financing to increase your sales?
* Would you like to receive our monthly e-mail updates/promotions? (1-2 e-mails max per month)
* How many clients will you quote a finance option to per month?
The applicant authorizes Horizon Keystone Financial, its designee, assigns or potential assigns, to review his/her business credit profile provided by national credit bureaus in considering this application and for the purpose of the update, renewal, or extension of credit to the applicant. By checking this box, you agree to the terms and conditions.

*Name (authorized signature):  Title:
*Email: