Vendor and Distributor Program
Non-Profit Distributor Application Form

* Indicates Required Field

CONTACT INFORMATION

First Name: *
Last name: *
Business Name: *
Business Address: *
City: *
State: CALIFORNIA
Zip Code: *
Phone Number: - -
Email Address: *

AGENCY INFORMATION

EIN or Tax ID Number: *
Type of Charity/Agency:

Other:

NAME OF HIGHEST RANKING OFFICAL

Title: *
Phone Number: - -
Description of clientele
served by your organization:
*
Will you provide passes free to your clients?
Will you be purchasing passes in the


By submitting this Form, affirms that the organization represented is in good standing with the IRS and is organized and operated exclusively for tax exempt purposes set forth in section 501(c)(3) or 501(c)(4). Applicant further agrees that all passes purchased under this program will be distributed by agency or non-profit entity to clients at no charge, or sold at a price not to exceed the purchase price of the pass paid by the agency or non-profit entity.

I have reviewed and agree to the Terms of Use and Privacy Policy of OCTA.net. *