Dealership Sign Up Form

Apply below to become an approved Auto Service Plan dealership

Applicant Contact Details

Applicant Name *

Applicant Position *

Email Address *

Applicant Contact Phone Number *

Dealership Business Legal Name *

Dealership Name *

Dealership Address Line 1 *

Dealership Address Line 2

Dealership Suburb *

Dealership City *

Dealership Postcode *

Dealership Contact Name

Dealership Phone *

Dealership Fax

Dealership Contact Email *

Dealership Company Number *

Date Established *

Billing Address Line 1 *

Billing Address Line 2

Billing Address Suburb *

Billing Address City *

Billing Address Postcode *

Details of Owner [If Sole Trader] Partners [If Partnership] or Director [If Company] or Trustees [If a Trust]

Sole Trader

Partnership

Company

Trust

Home Address Line 1 *

Home Address Line 2

Home Address Suburb *

Home Address City *

Home Address Postcode *

I accept the terms and conditions.

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