Application Authorized Dealer Program BUSINESS INFORMATIONBusiness Name(Required)DBA (if applicable)Primary Contact Name(Required) First Last Title/Position(Required)Phone(Required)Email(Required) Website(Required) Business Address(Required) Street Address Address Line 2 City ZIP Code Service Area (Counties/Regions Covered)(Required)BUSINESS TYPE & OPERATIONSDealer Type (check one)(Required) Contractor / Installer Wholesale Distributor Other How do you use or promote Champion products in your business?(Required) Actively install Champion products Stock Champion products for resale Market Champion products through sales, advertising, or displays Other Do you have a physical storefront or warehouse?(Required) Yes No Number of Employees(Required)Years in Business(Required)LICENSING & INSURANCEContractor License NumberLicense Issuing State State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific License Expiration Date MM slash DD slash YYYY Liability Insurance ProviderLiability Insurance Policy NumberLiability Insurance Policy Expiration Date MM slash DD slash YYYY Please Attach links/screenshots of reviews Drop files here or Select files Max. file size: 256 MB. PURCHASE & PERFORMANCE EXPECTATIONSEstimated Annual Champion Purchase Volume(Required) $12,000–$19,999 $20,000–$24,999 $25,000+ Current Champion Product Categories Used or Stocked(Required) Valves Spray Heads Nozzles Rotors and/or Impulse Actuators and/or Vacuum Breakers Ball Valves, Fittings, and/or Hose Bibs Do you currently work with a Champion sales rep?(Required) Yes No Name of Current Champion Sales Rep(Required)REPUTATION & REFERENCESDo you have online reviews?(Required) Yes No Please Provide Link To Online Review Rating (Google, Yelp, Nextdoor, etc.)(Required) Please Provide Two Professional References Below (Name, Company, Phone and/or Email)(Required)MARKETING INTERESTS & SUPPORT NEEDSWould you like support with the following? (Check all that apply) Co-branded apparel Signage (storefront, counter, yard signs) Digital marketing templates Social media content NHRA tickets (based on tier) Product training Are you interested in joining the Champion Dealer Advisory Board?(Required) Yes No SIGNATURE & AGREEMENTConsent(Required) By submitting this application, I certify that the information provided is accurate to the best of my knowledge. I understand that acceptance into the Authorized Dealer Program is based on meeting Champion’s eligibility criteria and approval process.Your Comments/Questions Helping Things Grow Since 1937 Explore Products
