Midway Bicycle Supply Dealer Application

Thank you for your interest in establishing an account with Midway Bicycle Supply. We offer quality products, excellent customer service, dealer only access to pricing and great pricing. Please complete the following application. If you have questions you may email us at info@midwaybike.com or call us at 651-955-1930.
Midway Bicycle Supply Dealer Application
Legal Business Name *

Business Name DBA (Doing Business As)
Years in service
Number of locations
How to receive invoices

Billing Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Manager's Name *

First Name Last Name
Buyer's Name *

First Name Last Name
Owner or Principal's Name *

First Name Last Name
Username *
Enter the username for online access
Password *
Enter the password you would like for online access

Shipping Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail *
Phone Number *

Area Code Phone Number
Website

Terms and Conditions

It is agreed that a service charge of 1 1/2% per month may be charged on all delinquencies, or the highest rate permitted by prevailing law, whichever is lower. In the event your account requires either legal action or the sevice of a collection agency, your are responsible for all fees that accrue as a result of such action. If your check is returned by the bank as uncollectable, a $30.00 service charge will be aded to your account and your account terms will be changed to credit card or cash up front. Midway Bicycle Suppy, Inc. reserves the right to change your account terms at any time. We open all accounts with Net 30 days, no credit check required.

It is agreed that Liability insurance is and will remain in place.

I affirmatively attest that I have read, clearly understand, and agree to the terms and conditions noted in the applicaton on behalf of the applicant. The information provided herin are complete, accurate, and truthful. I am authorized to execute this application.
Authorized Signature *

Clear
Printed name *

First Name Last Name
Title *
Date *

Month Day Year Date Picker Icon
State Sales Tax Exemption Number *
Liability Insurance company *
Liability Insurance policy number *
Enter the message as it's shown *
Should be Empty:

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