Dealer Application Form

Company Name*
Owner's Name*
First Last
Address*
Street Address City State ZIP Code
Phone*
Email*
Website
Years in Business
Tax Permit # (no dashes or symbols)*
Business License # (no dashes or symbols)*
Consent*
I agree to the privacy policy.
Indemnity: Buyer shall indemnify and defend Curly’s Inc. and it’s affiliates against any and all loses, damages and expenses (including attorney’s fees and other cost of defending any action) that it may sustain or incur as a result of: (I) The use, operation or possession of the products by buyer, (II) The alteration or modification of the products or the use or combination of the products with other products or devices by buyer, (III) A negligent or willful act or omission of buyer, (IV) The breach by buyer of this contract, or (V) The failure of buyer to comply with any applicable law or regulation.