Dealer Referral Program
Registration Form

Your name:
City:            State: Postal Code:


Biz Tel:      Biz FAX:
800 Tel:      e-mail:     

What of the following products do you sell and/or service? Check all that apply.

 Sell    Install     Service & accessories
                                  CB Radios
                                  Amateur radios and accessories
                                  Cellular telephones and accessories
                                  Marine radios and accessories
                                  Business radios and accessories
                                  Frequency scanners and accessories

Do you do mail/phone order sales?         YES   NO
What credit cards do you accept? Mastercard Visa Discover Amex

What CB radio brands do you carry?  
What CB antenna brands do you carry?

Who are your two main suppliers for Firestik Antenna and Accessory products?
Supplier 1:
Supplier 2:

What Firestik® products do you normally carry on a regular basis?  Check all that apply.

ANTENNAS: Firestik Firestik II Fire-Fly RoadPal Scanner

KITS:           Firestik Firestik II Fire-Fly RoadPal No-Ground Plane

OTHER:        Firestik Accessories Roadpal Accessories

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