IMOTO CONCEPTS DEALER APPLICATION
* REQUIRED INFORMATION

                                                                                                      GENERAL BUSINESS INFORMATION

  BUSINESS NAME : *  OWNER FIRST NAME : *  OWNER LAST NAME : *

  ADDRESS: *  CITY: *  STATE: *   ZIP: *  PHONE: *

  YEARS/MONTHS AT ADDRESS: *  CONTACT PERSON : *  EMAIL : *  WEBSITE : *

                                                                                                                   LICENSE INFORMATION
                                                                                                                             (PLEASE FAX OR EMAIL A COPY OF THESE ITEMS FOR YOUR FILE)

  FED. TAX I.D.: *   BUSINESS LICENSE NUMBER : *  STATE RESALE NUMBER : *
  I AGREE TO EMAIL OR FAX THE ABOVE ITEMS FOR MY FILE

                                                                                                                  BANKING INFORMATION

  BANK NAME: *   NAME ON ACCT.: *  BUSINESS ACCOUNT? (Y/N): *
  I AM A SOLE PROPRIETORSHIP AND THE ACCOUNT IS A PERSONAL ACCOUNT

                                                                                                    TRADE REFERENCES/MARKETING INFO

  TRADE REFERENCE 1: *   LENGTH OF ACCT.?: *  CONTACT PHONE: *

  TRADE REFERENCE 2: *   LENGTH OF ACCT.?: *  CONTACT PHONE: *
  I ADVERTISE ON INTERNET FORUMS
  I ADVERTISE IN NATIONAL MAGAZINE PUBLICATIONS
  I ADVERTISE ON LOCAL RADIO AND/OR TELEVISION