4225 Fallston Road, Shelby, NC 28150

(704) 538-3512 info@derisiracing.com

Dealer Application

Download our dealer application to fill out and mail it back to us, or fill out the form below.  Please make sure to fill out all of the info. Contact DeRisi racing if you have questions regarding the application. They are processed in the order in which they are received. To correct errors on your listing (or if your listing is missing) in the Dealer Network, please contact us.

Click here for dealer application in pdf format.

    Dealer Application

    Your Full Company Name (required)

    Contact Email (required)


    Phone number:

    Billing Address:

    Shipping Address:

    Owner's Name:
    Home/Cell Phone:

    Type of business:CorporationProprietorshipLLCPartnershipOther
    We are a:DealershipRepair/Service CenterRetail ShopATV etc.Motorcycle etc.Other

    Federal Tax ID: Years in business:

    Names of Authorized People to Place Orders:

    Are purchase orders required? [Checkbox* PO "Yes" "No" "Please Contact"]

    Accounts Payable Contact
    Name: Phone:

    I AGREE By checking this box and clicking submit you agree that you are an official employee acting on behalf of the company listed at the top of this application and that you are authorized to do so. This is not a binding contract and DeRisi Racing reserves the right to refuse service to anyone.

    Your Name: Your Position:
    Your Phone:
    Your e-mail:

    We hate spam and will never sell your information!