If you have any questions concerning your account, contact customer service at
customerservice@coastalsource.com

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Dealer Application

STEP 1 of 3 - BUSINESS GENERAL INFORMATION

* Denotes Required Field

Name & Company Information

First Name*

Last Name*

Title

Company Legal Name*

DBA

Company Web Site

Email*

Company Phone*

Company Fax

Tax ID*

Tax Exempt:*

Yes

No

Note: If you selected "Yes" for tax exempt status, we will contact you for verification.

Company Profession*

How did you hear about Coastal Source?

Are you working with a Coastal Source rep? Please provide rep's name, company and other relevant information.

Yes

No

If yes, please explain.

Billing Address

Address*

Suite/Office #

City*

State*

Zip*

Shipping Address

Check if same as Billing Address

Address*

Suite/Office #

City*

State*

Zip*