Fields marked with an *Asterisk are required unless your country does not have states or provinces.

COMPANY INFORMATION

*Company Name/Name:
DBA(Doing Business As):
*Primary Contact Person:
*I would like to be:  Authorized Reseller  Custom Tuning Dealer
*Already selling SCT/Bully Dog products?  No  Yes
I purchase SCT/Bully Dog products from:
*Address Type:
*Country:
*Address 1:
Address 2:
*City:
*State/Province:
*Zip/Postal Code:
*Phone#:
*Email Address:

BILLING INFORMATION

 Billing Address same as above:
*Billing Address Type:
*Billing Country:
*Billing Address 1:
Billing Address 2:
*Billing City:
*Billing State/Province:
*Billing Zip/Postal Code:
*Billing Phone#

ADDITIONAL INFORMATION

*Do you have a Dyno?:
*Do you have a storefront?:
*Tax ID #:
*State/Province of Registration:
*Website, if multiple separate by comma:

Please allow up to 24 business hours for approval. If approved, you will receive an Authorized Reseller Agreement to review and sign electronically via DocuSign. Contact MAP@derivesystems.com with any questions.