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Pro Series Dealer Direct Sign Up

Legal Company Name *

Principle First Name *
Principle Last Name *

Principle Title *

Street Address *

Apt, floor, suite, etc.

City *
State *
Zip *

Phone *
E-mail *

BUSINESS INFORMATION

Other Organization Type

State of Incorporation *
Year Established *

Trade / DBA Name(s)
Trade / DBA Name(s)
Trade / DBA Name(s)

Address *
State *
Zip *

Phone Number *

BUSINESS PROFILE

Website Address
Website Address
Website Address

Go-to-Market Strategy *

Marketplace PresenceYesNo
Amazon Reseller Name
Walmart Reseller Name
eBay Reseller Name

Alibaba Reseller Name
Other Reseller Name (provide website and name)

Procurement Channel(s)

Comments

I agree all the above information is true and that if approved, we will comply with Antenna Direct and Mohu dealer requirements.

Print Applicant Name *

Current month ye@r (4 digits) day *