Dealer Application

Address:

Billing Address:

Business Information:

CorporatePartnershipSole ProprietorshipIndividual

Authorization

The information above is given for the purpose of establishing eligibility for a credit account with Mobility Unlimited, Inc.

Mobility Unlimited, Inc. is hereby authorized to make any credit inquiries for approval. I certify that all of the information above is correct and that I have the authority to incur liabilities and enter into this agreement in the name of the company.

Applicant Full Name (required)

By clicking the Submit Form button the applicant agrees all information is true and accurate and authorizes submission.