Dealer Registration Form

Logjam Electronics is selling directly to authorized Car Audio Dealers and Retailers at discounted prices. For the purpose of your company obtaining products at Dealer pricing, Logjam Electronics is relying upon the information provided below as true and correct. To set up your account as an authorized Logjam Electronics' Dealer, please fill out and submit the following registration form.

BUSINESS INFORMATION
    Name of Business:       Phone #:       FAX #:
    Principle's Name:            Phone #:
    Contact's Name:           Phone #:
    Contact's E-Mail Address:

    Type of Business:          Individual     Proprietorship    Partnership    Corporation    LLC
    Years in Business:     0-2                  3-5                    6-10             11+
    No. of Employees:       0-5                  6-10                    11-15             16+
    Federal Tax Number:          Resale Tax ID Number:

    Shipping Address:
        Street:
          City:         State:      Zip:

FINANCIAL INFORMATION (All information sent over secure SSL Network)
    Credit Card Number:       Expiration Date (MM/YYYY):
    Credit Card Type:    American Express    Discovery    MasterCard    Visa
    Billing Address:
         Street:
          City:         State:      Zip:
CHECK HERE IF YOU NEED TO ORDER PRODUCTS TO SHIP TODAY!
        (Must be submitted on a business day before 4:00pm Eastern time to receive immediate assistance)
CHECK HERE TO ADD YOUR BUSINESS TO OUR LIST OF DEALERS WHO PROVIDE INSTALLATION SERVICES.
(Click HERE for additional information)