Service Dealer / Central Distributor
Information Change Form

Type of Change
Information Only	Stanadyne I.D.# -
Cancellation
New Dealer*
*Note: If "New Dealer" is checked, Product Support will evaluate the request and provide a new I.D. number.
Distributor Representative Date:

Required Change	Previous Information	New Information
Name
Address
City
State
Zip Code
Latitude
Longitude
Phone
Fax
E-Mail
Web Address
Certification Status (IFS, DE, DS) - Describe change in Distributor Comments box.

Distributor Comments: