Dealer Application VERSION EN FRANÇAIS ---> Dealer Card BILLING NAME AND ADDRESS ADDRESS CITY PROVINCE Quebec Ontario New-Brunswick Alberta Saskatchewan Manitoba British Colombia Nova Scoia Newfoundland POSTAL CODE TELEPHONE # IN BUSINESS SINCE COMPANY TYPE WEBSITE PRODUCTS INTERESTED IN Moto Products Bicycle Products ALL FIRST CONTACT EMAIL TELEPHONE + EXT PURCHASING CONTACT EMAIL TELEPHONE + EXT ACCOUNTS PAYABLE EMAIL TELEPHONE + EXT DIRECT DEPOSIT PAYMENT METHOD CHECK PAYMENT METHOD ACCES D PAYMENT METHOD CREDIT CARD PAYMENT METHOD SHIPPIND NAME AND ADDRESS (leave blank if the same) SHIPPING ADDRESS (leave blank if the same) SHIPPING CITY SHIPPING PROVINCE Quebec Ontario New-Brunswick Alberta Saskatchewan Manitoba British Colombia Nova Scoia Newfoundland SHIPPING POSTAL CODE SHIPPING TELEPHONE # MESSAGE APPLICANT NAME FUNCTION Authorization The applicant acknowledges that he has the authority to open an account on behalf of the company. SUBMIT Address 136 1st Avenue Stoneham-et-Tewkesbury, QC, G3C 2N1 E-mail info@kappadistribution.com www.kappadistribution.com phone Contact Us (833) GO-KAPPA