Bluecube Lifeline Dealer Application

Dealer Application

BLUECUBE LIFELINE
950 Milwaukee Ave.
Suite 216
Glenview, IL 60025
888-742-7244
support@bluecubelifeline.com
BUSINESS INFORMATION
Legal Business Name: *
DBA (Doing Business As (if different)):
Federal Tax ID: *
Principal Owner Name: *
Business Contact Name (if different):
Business Phone Number: *
Owner’s Phone Number:
Contact Person’s Phone Number (if different):
Business Address: *
City: *
State:
Zip Code:
Type of Business: *
E-mail address:
Company Type: (Check One)
Proprietorship | Partnership | Corporation | Other

AUTHORIZATION

By signing below, I warrant to BLUECUBE, Inc. (“BLUECUBE LIFELINE”) that (1) I am an authorized representative of Applicant, (2) I have full authority to sign this Dealer Application on behalf of Applicant and (3) to the best of my knowledge all of the information contained in this Dealer Application is true and correct. I agree to pay all obligations due bluecube for services and products provided by Bluecube. If Bluecube takes action to collect any unpaid balance of Applicant, I agree to pay the actual attorney fees, costs and expenses incurred, plus interest at the highest rate authorized by law.

Print Name:
Date:
Please sign below with your mouse or using touch-screen display. *


NOTE:

Please attach a copy for the following documents to your completed application:
1. Copy of Principal Owner’s Driver’s License
2. Business License (any kind except expired one) or Utility bill which states current business Name and Address


Failure to complete entire application or attach requested documents will cause delays in the dealership request process.
Please send legible copies of application and required documents to: support@bluecubelifeline.com (Photo copies accepted)