Become a Dealer Distributor Application Form If you are interested in becoming a distributor for ICON Vehicle Dynamics, please read and fill out our online application form below in its entirety. We also have a Printable Form: Click Here to Download the PDF. (Fax completed form to 951-689-1016) Thank you! Company InfoCompany Name:* Company Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone:*Example: 9516894266 (NO SPACES)Fax:Federal Tax I.D.:*Example: 95-123456Seller Permit Number:*Company Website Address: Sales E-Mail Address: Accounting E-Mail Address: Sales Info:What vehicles makes do you deal with the most? (i.e. Ford, Toyota, GM etc.):How do your customers hear about you? (i.e. Word of Mouth, Online, etc.):Do you advertise in your city? (i.e. Billboards, Signs, etc.):Do you advertise online? (i.e. Banner Ads, Company Website etc.):Do you have an online store?:YesNoDo you have a showroom where you display the products you sell?:YesNoDo you offer installation?:YesNoContact Info:Owner's Name: First Last Accounts Payable Clerk: First Last List Authorized Purchasers:In order to complete this application, a copy of your Re-Sale Card and Business License MUST be faxed in to 951-689-1016. All orders will be shipped PrePaid. For open account terms, a Credit Application must be completed and approved by the ICON Vehicle Dynamics Accounting Dept. 7929 Lincoln Ave. Riverside, CA 95204 | ph. 951.689.ICON | fx. 951.689.1016Image VerificationThis information may be shared with an authorized ICON distributor, completion of this form and clicking ‘Submit’ indicates you agree to these terms.
