Dealer Application - Millennium Technologies

1404 Pilgrim Road • Plymouth WI 53073
phone: 920-893-5595 • fax: 920-893-4830 • email: info@mt-llc.com

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Dealer Application

Click icon to download a printable dealer application form or use the online form below.

In order to complete the processing of either form, we will need a copy of either your business license or your seller’s permit faxed to us at 920-893-4830.

Date:

Business Name:

Street:

City/State/Zip:

Phone # Day:

Phone # Evening:

Fax:

Email:

Website:

Owner:

Contact:

Type of Business:

Federal E. I. #:

Year Established:

State Seller's Permit #:

In order to complete the processing of either form, we will need a copy of either your business license or your seller’s permit faxed to us at 920-893-4830.

Reference

Preferred Shipping

Please pick one choice:
UPS Ground 3 Day 2 Day Next Day Next Day Early
FED-EX 3 Day 2 Day Standard Priority Overnight

Payment: C.O.D. Credit Card

Card Type

Card Number

Expiration Date

Cylinder Head Repair Link. We can fix your cylinder heads!

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