1. Please provide the following contact information:

   First Name
   Last Name
   Middle Initial
   Title
   Organization
   Office Address
   Address (cont.)
   City
   State/Province
   Zip/Postal Code
   Country
   Store Address
   City
   Work Phone
   Home Phone
   FAX
   E-mail
   Web Site

2. Please enter your State or Provincial Sales Tax Number below:
   
3. Do you have multiple store locations?  Please enter city locations below:
4.     
       
       
       
5. Do you own the property at your primary business location Yes  No OR do you operate from a leased facility with a lease duration of at least one year?  Yes  No
6. 
   New dealers are required to place an initial stock order of 6 units.  Are you willing to order the minimum of 6 units to qualify as a dealer?  
   Yes  No
7. 
   Dealers are required to have a service capability to advise customers and perform repairs.  Do you have personnel capable of performing such repairs using manuals provided? 
   Yes  No
    

Valuride is pleased to offer the finest electric bicycles designed to provide long hours of carefree enjoyment to our customers.  We maintain a substantial stock of spare parts for all of our products to insure trouble-free enjoyment and quick repairs when necessary.  We will be happy to have you on our team.  We will contact you promptly when we receive this completed form and will be happy to answer any further questions you may have.  You may also call us directly at 250-545-6668.