Complete the form fields, print, sign, and fax to (800) 523-5729
Your Dealer #:
Purpose of your application :
PRIMARY USER INFORMATION - SUPERVISOR
Supervisor receives all APD ORDER e-mail notifications for each additional user.
The I.P. address for each login session will be recorded to help deter unauthorized access.
First Name
 
Last Name
Position/Title
  
E-Mail
NOTE: email address must be unique from other users to receive user specific email notifications regarding placed orders, changes to user specific login I.D. or password information

FOR APD USE ONLY


ADDITIONAL USER INFORMATION
The I.P. address for each login session will be recorded to help deter unauthorized access.
First Name
 
Last Name
Position/Title
  
E-Mail
Allow user to submit orders?
YES
NO
 
NOTE: email address must be unique from other users to receive user specific email notifications regarding placed orders, changes to user specific login I.D. or password information

FOR APD USE ONLY


ADDITIONAL USER INFORMATION
The I.P. address for each login session will be recorded to help deter unauthorized access.
First Name
 
Last Name
Position/Title
  
E-Mail
Allow user to submit orders?
YES
NO
 
NOTE: email address must be unique from other users to receive user specific email notifications regarding placed orders, changes to user specific login I.D. or password information

FOR APD USE ONLY


ADDITIONAL USER INFORMATION
The I.P. address for each login session will be recorded to help deter unauthorized access.
First Name
 
Last Name
Position/Title
  
E-Mail
Allow user to submit orders?
YES
NO
 
NOTE: email address must be unique from other users to receive user specific email notifications regarding placed orders, changes to user specific login I.D. or password information

FOR APD USE ONLY

I hereby authorize the above employees to utilize online ordering from Advantage Performance Distributing, Inc. for my company. I understand that all orders placed online will be subject to my current account terms and conditions. I understand that it is the responsibility of the Dealer to keep User Names and Passwords confidential. Handwritten signature required below.

   
PRINTED NAME of authorized agent Title
   
SIGNATURE of authorized agent Date