Authorized Aprilia Dealer Application Form

Please complete the following information to facilitate further contact with you.

Highlighted items are required.

Your Contact Information
First Name: Last Name: Email: Phone:
Your Company Information
Company Name:
Type of Business:	Choose Type Individual (Sole Proprietor) Corporation Limited Liability Company Partnership Limited Partnership Other
DBA:
Owner's First Name:
Owner's Last Name:
Street:
City
State/Province	Choose State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip/Postal Code
Country
County
Business Telephone:
Business Fax:
Website
Number of Locations:
Number of Years in Operation:
Current Annual Revenue:
Total Credit Line:
Number of Employees:
Industry:	Choose Industry European Powersports Japanese Powersports American Powersports Multi-OEM Powersports Multi-OEM Scooters Auto and Powersports Auto only Other
Real Estate:	Choose Real Estate Mortgage Lease Own
Current Floorplan Financing Provider:	(e.g., GECDF, Honda Financial, Textron, Local Bank, N/A, etc.)
Dealer Management System Provider:	Choose Dealer Management System Provider ADP Lightspeed MIC Systems C Systems Talon ARI PartSmart IDS Dockmaster Other None
Current Brands Carried:	Aprilia BMW Arctic Cat BRP Buell Ducati Harley-Davidson Honda Husqvarna John Deere Kawasaki KTM Moto Guzzi Piaggio Polaris Suzuki Triumph Vespa Victory Yamaha Other (specify):   None/Not a Current Dealer
Your Proposed Dealership Facility
Address is same as above (check here):
Address (Proposed):
City (Proposed):
State/Province	Choose State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip/Postal Code (Proposed):
County (Proposed):
Area (in square ft):
Zoned for Motorcycle Sales:	Yes   No
Zoned for Motorcycle Service:	Yes   No
Tell Us About Yourself: (please include why you would like to open a dealership, why the dealership location you propose is attractive, how you plan to market our brand, etc.)
Notice to all applicants:	This is an Application for Dealership only. Piaggio Group Americas (PGA), does not assume any obligation or liability for any cost or expense incurred in preparing or submitting this application, nor for any liability or obligation contracted by any parties submitting this Application. All Applicants MUST BE APPROVED BY PGA and Sales and Service Agreements entered into and executed by both parties and delivered to you before a dealership relation can commence. All Agreements, orders or any document, paper, or instruments submitted with such Application shall not be binding upon PGA until Sales and Service Agreements are duly executed by both parties.
	I have read the foregoing paragraph and certify all statements and financial conditions on the attached financial statement to be true and complete.

Thank you for your interest and your passion. We look forward to receiving your information.