Excelerate LLC 12 Sycamore Way Unit 1 Branford, CT 06405 Phone: 203-483-6100 Fax: 203-483-6104 Email: [email protected] Website: www.ExceleratePerformance.com

DEALER APPLICATION Company Name: ___________________________________________________________________ Ship To Address: ___________________________________________________________________ Bill To Address: ____________________________________________________________________ Telephone: ______________________________ Email: ____________________________________ Type of Ownership: O Sole Proprietor O Partnership O LLC O Corporation Federal Tax ID Number: ____________________ Resale Tax ID: ____________________________ Authorized Purchasing Agent(s):_______________________________________________________ TRADE REFERENCES Company: ____________________________

Company: _______________________________

Phone: _______________________________

Phone: __________________________________

Contact: ______________________________

Contact: _________________________________

Thank you for your interest in purchasing from Excelerate LLC dba Excelerate Performance. This application is necessary for the purpose of establishing a wholesale account. Excelerate LLC or its agent(s) are authorized to verify any information submitted to them. Please visit www.excelerateperformance.com/terms.htm for our Terms and Conditions. Your signature below demonstrates that you accept our terms and conditions and that the above information is warranted to be true and complete. Please fax this application back to us at 203-483-6104. PLEASE MAKE SURE TO INCLUDE A COPY OF YOUR BUSINESS AND/OR RESALE ID.

Authorized Signature: ______________________ Title: ___________________________________

Printed Name: ____________________________ Date: ___________________________________