Prime Acceptance Corp - Dealer Services

Prospective Dealers:

If you are interested in becoming a dealer of our services, please fill out the form below. Alternatively you can download an Adobe Acrobat copy of this form and either fax or mail it back to us.

Dealer Application Form Download

Dealer Application

Company Name: Tax I.D. No.:
Principal Name: SS#:
Address:
City: State: ZIP:
Phone: Fax:
Merchandise/Product:

Company Bank:
Bank Phone:
Account No.: Contact Name:

Please list 3 credit references with which your company does business

Company:	Company:	Company:
Address:	Address:	Address:
City, State, ZIP:	City, State, ZIP:	City, State, ZIP:
Phone:	Phone:	Phone:
Contact:	Contact:	Contact:

By clicking submit, I/We certify that the foregoing statements are true and complete. I/We agree that this application shall remain in PAC's possession whether or not a dealer agreement is entered into. PAC is authorized to make any and all inquiries deemed necessary to verify the accuracy of the statements made herein, and to determine my/our creditworthiness by procuring consumer credit reports and business credit reports from consumer and business credit reporting agencies and by obtaining credit information from other financial institutions and creditors.