Please note that all fields marked with an * are required.
Legal Business Name	*
DBA
Website Address
Type of Entity	*	- Select - Individual Partnership Corporation Subchapter S LLC LLP
Federal Tax ID or Social Security	*
Year Incorporated	*	- Select - 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950
Number of Years in Business	*	- Select - Less than 2 years 2-5 years 5-10 years 10+ years
Number of Locations	*	- Select - 1 2-5 5-10 10+
How Do You Sell?	*	On the Internet Via Mail Order In Store Other (specify below)
How Do You Sell (Other)
What Do You Sell?	*	Complete Bikes Frames Components Accessories Other (specify below)
What Do You Sell (Other)
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Shipping Address 1	*
Shipping Address 2 (Apartment, Suite, Unit, Building, Floor, etc.)
Shipping Address 3 (Department, C/O, etc.)
City	*
State	*	- Select - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code	*
UPS Shipping Account Number (If you prefer to have your shipments sent Collect)
Reenter UPS Shipping Account Number
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Billing Address 1	*
Billing Address 2 (Apartment, Suite, Unit, Building, Floor, etc.)
Billing Address 3 (Department, C/O, etc.)
City	*
State	*	- Select - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip	*
Check if same as shipping address		Yes
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Owner or Principal’s Name	*
Owner or Principal’s Telephone #	*
Owner or Principals’s Alternative Telephone #
Owner or Principal’s Email Address	*
Primary Contact’s Name	*
Primary Contact’s Main Telephone #	*
Primary Contact’s Alternative Telephone #
Primary Contact’s Email Address	*
Other Contact’s Name
Other Contact Main Telephone #
Other Contact’s Alternative Telephone #
Other Contact Email Address
Other/Comments/Special Requests
You will be notified via email once your online application is approved.* Upon receipt of this email, you may begin to place orders online as an Authorized RASE Dealer simply by signing in under FOR DEALERS with the email and password you used when you created your online account. Your RASE Dealer discount will automatically be applied during the checkout process where you can make payment securely via Credit Card or PayPal. Should you have any questions regarding the online application process, please feel free to CONTACT US. Thank you. *Please allow up to 48 hours for your online application to be reviewed and approved.