Please check all that apply:

(Fields marked * are Required)

• I am an authorized Bridgestone Firestone dealer/distributor
  • My account number is: *
• I am authorized to purchase the following BFNT products. (check all that apply)*
  • Passenger/Light Truck Tires
  • Commercial Tires
  • Off The Road Tires
  • Agricultural Tires
• I maintain an inventory adequate to meet the needs of those government agencies that I service.*
  • Yes No
• I have a dedicated government sales person at my location. (This is a person at your location that can answer questions and inquires from government agencies and someone that should receive communications from the BFNT Government Sales Dept regarding bids and approvals in your area.)
• First Name:  *
• Last Name:  *
• Phone: *
• E mail: *
• I have company owned delivery trucks.*
  • Yes No
• I am authorized to use BFNT BFDI/EntireNet and I have email.
  • E-mail address: *
    
  • Additional E-mail address1:
    
  • Additional E-mail address2:
    
  • Additional E-mail address3:
    
  • Additional E-mail address4:
    
• I have received, read and understand the 2007 Bridgestone Firestone Government Policy brochure and agree to abide by the policies and procedures listed therein.*
  • Yes No

First Name:	*
Last Name:	*
Company Name:	*
Company Address:	*
City:	*
State:	*
Zip:	*
Federal Tax ID:	*

• Optional: I am a minority business owner. Please specify category: African American Asian American Hispanic American Native American Woman-owned Veteran Disadvantaged Business HubZone Service Disabled Veteran Small Business (<100 employees)
• Optional: Please list other states that you service by entering the two-digit state code.

State1:
State2:
State3:
State4:
State5:
State6:
State7:
State8:
State9:
State10: