GIADA Dealer Membership Application (pre-license)

I am in the process of becoming a licensed Used Car Dealer or Rebuilder.

Membership Form

Growing your dealership starts right here and right now.

GIADA Dealer Member *

Dealer Applicant - $ 250.00

GIADA PAC Fund

$25 $50 $75 $100 - none -

Other Amount

If you would like to make a donation to the GIADA PAC Fund, please indicate the amount

Total Amount

On Behalf Of Organization [Applicant]

Membership Name *

Enter company name, if you do not have a company name, enter your first and last name.

Membership Email *

Mailing Address

Street Address *

City *

State *

Zip Code *

If you would like to create an account on this site, check the box below and enter a Username and a password. If you already have an account please login before completing this form.

Create an account?

Username

Check Availability
Punctuation is not allowed in a Username with the exception of periods, hyphens and underscores.

Password

Confirm Password

Provide a password for the new account in both fields.

My Contact Information

First Name *

Last Name *

Email *

Mobile Phone

Credit Card

Card Type

Card Number *

Security Code *

Expiration Date *

Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

Street Address *

City *

Country *

State/Province *

Postal Code *