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Dealer Application

Applicant Overview

The undersigned applicant ("Applicant") submits this Application to Segway Ninebot Philippines
(All non-public information about Applicant provided on this Application shall be held in
confidence by Segway Ninebot Philippines)

* Indicates required field

Full legal name of Applicant *

First

Last

Trade Names under Applicant does business *

Date incorporated or otherwise organized *

Place of incorporation or organization *

APPLICANT'S OFFICE ADDRESS

Address Line 1 *

Address Line 2 *

City *

Province *

Zip / Postal *

Applicant's telephone / mobile number *

Applicant's website *

Applicant's Email Address *

Please add me to the Segway email list for company, product and event updates *

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