Weller Racing LLC.

Dealer Application
3200 N Delaware St Chandler, AZ 85225
Ph: 480-507-4771 Fax: 480-467-4202
www.WellerRacing.com

Applicant Information: (Please include: Business License, Storefront Pictures, Voided Check)
Business Name: ________________________________________________________________
Business Phone: ___________________________ Fax: _________________________________
Email Address: _________________________________________________________________
Website Address: _______________________________________________________________
Type of Business (circle all that apply): Service / Online Parts / Vehicle Sales / Parts Counter

Billing Address:
______________________________________________________________________________
City: _______________________________ State: ________ Zip: _________________________

Shipping Address: _______________________________________________________________

City: _______________________________ State: ________ Zip: _________________________

Reference: _____________________________________________________________________
Reference: _____________________________________________________________________
Reference: _____________________________________________________________________

Credit Card Information:

Credit Card Number: ____________________________________________________________
Type of Card: ___________________ Exp: __________________ 3-Digit Code: ______________
Name on Card: _________________________________________________________________
Keep card on file? O Yes / O No
By signing this document, you are agreeing to let Weller Racing LLC. charge your card for verbal and or
email orders. You are agreeing to let Weller Racing LLC. keep your card information on file for future
use. All orders returned are subject to a 25% restocking fee.

Name: _________________________ Signed: __________________________ Date: _________

Please Fax completed forms back to 480-467-4202 or Email: dealer@wellerracing.com