Midcity Engineering

Authorized Reseller Application

Proceed below to sign this form electronically. If having trouble with online form, please contact Mid City Engineering at 312-421-1114.

Dealer Name:

Please enter your email address:

* Website:

DBA:

* Address (no P.O. box):

City, State, Zip:

* Phone number:

Owner/President:

Tax ID Number:

How did you hear about Midcity Engineering?
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Other:

Additional Info:

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You agree that the information entered above is accurate. You are also confirming that you can legally act on the behalf of the party applying for authorized retailer status. If you do not agree with one or both of these statements, Midcity Engineering cannot grant the aforementioned party authorized retailer status.

By clicking agree, you are digitally signing this form. Midcity Engineering will hold your selection in the same regard as it would your written signature on paper.

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