a. Contact information
* First Name:
* Last Name:
Company Name:
Position:
Street Address:
* City/Town:
State/Prov:
Post/Zip Code:
* Country:
* Your email address:
Web site:
* Phone:
Cell:
b. Applicant information
I am interested in applying as a/an:	Dealer Franchisee Independent
Do you currently own and/or manage a business?:	Yes No
Length of your business:
What type of products do you currently offer or have offered in the past?:	sports goods recreational transportation entertainment clothing Other
Please specify the type and/or model of products if you offer Light Electric Vehicles:
Do you have any prior experience and/or knowledge related to Light Electric Vehicles? :	Yes No
Other comments:
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