Apply to be a Dealer

It's easy to apply to be a dealer with Ezra Distributing! Just fill out the form below at your convenience, and hit submit. Any time, day or night. We'll review it, and contact you with your account information if it is approved! You may also download our offline application, fill it out, and fax it to us at 765-807-6478.

Confidential Credit Application

State :: Canadian Provinces at the Bottom of the List
        ZIP*


Owners or Principals



Owner 1



Owner 2



Owner 3



Business Info




Sales Tax Exemption # :: If Applicable, Email or Fax Us Your Exemption Certificate

Are you a division or subsidiary of another company? If so, please list name and address of parent.

Supplier References

Please provide complete mailing address. References should be suppliers who supply equal or more credit than expected from Ezra Distributing, Inc. Please do not list competitors of Ezra Distributing, Inc. Please list three or more.


Supplier 1



Supplier 2



Supplier 3



Supplier 4



Bank Reference



Bank 1

State :: Canadian Provinces at the Bottom of the List
        ZIP


Bank 2

State :: Canadian Provinces at the Bottom of the List
        ZIP


Credit Information



Account Information



Bill to:

State :: Canadian Provinces at the Bottom of the List
        ZIP*


Ship to

State :: Canadian Provinces at the Bottom of the List
        ZIP


Misc.









Classification :: Choose at Least One


Terms of Application

  1. We will notify Ezra Distributing Inc. of any change in ownership of our company.
  2. If granted credit, our company agrees to pay all invoices within 30 days of invoice date.
  3. It is agreed that our account 30 days past due will be charged 2% interest per month and future shipments will be suspended. We will lose open account privileges with all future orders after our account is 60 days past due.
  4. Our company finacial condition is satisfactory and we can meet all financial obligations.
  5. There are no lawsuits or judgements against our company at this present time.
  6. If our company defaults on payment of any valid invoices, we agree to pay attorney or collection expenses.
  7. We will notify Ezra Distributing Inc. before returning parts.
  8. We agree that prices may change without notice.
  9. Send money order, check or credit card with order until credit is established. Shipping charges will be added to your invoice if orders are shipped out of continental U.S.
  10. Please state how you would like your order shipped. Please state if you want out of stock items backordered.
  11. Ezra Distributing Inc. reserves the right to sell to a:
    1. Dealer or distributor which is consistently deliquent concerning above terms and conditions.
    2. Dealer, which orders less than five carriers per year. Distributor, which orders less than twenty-five carriers per year.
    3. Dealer or distributor for any reason determined by Ezra Distributing Inc.
  12. I make the foregoing application for credit for the purposes of obtaining merchandice on an open account basis.
  13. I testify that all of the above information is correct and understand that forging information will cause a denial of my application.

***If you hit submit, and are not redirected for a new page, scroll up and ensure you have all the required fields properly filled out.***

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