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Dealer Credit Application
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Business Name
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Phone
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Business Address
City
State
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AR
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CT
DE
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GA
HI
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IL
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KS
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ZIP
Type of Ownership
Sole Proprietorship
Partnership
Corporation
LLC
Number of Employees
< 5
6 - 9
10+
Federal ID # (If Applicable)
State Resale #
Date Business Started
MM slash DD slash YYYY
Number of years under present management
Storefront
Yes
No
Website URL
Last Year's Total Sales
Less than $100,000
$100,000-$250,000
$250,000-$500,000
$500,000-$1,000,000
$1,000,000+
Principal Owner(s)/Applicant(s)
Full Name
*
Title
Hidden
Home Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Guam
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Maryland
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Mississippi
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North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP
Phone
*
Email
*
Hidden
SS#
Hidden
DOB
MM slash DD slash YYYY
Full Name
Title
Hidden
Home Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP
Phone
Email
Hidden
SS#
Hidden
DOB
MM slash DD slash YYYY
Accounting
Accounts Payable Name
Phone
Email
Credit References
Company
Name
Phone
Company
Name
Phone
Company
Name
Phone
Credit Terms & Conditions
Terms & Conditions
*
I/we certify that all information contained in this application is true and correct. I/we hereby authorize all companies and financial institutions with whom we do business to release information to Rogers Base Company, LLC. By signing below, and in consideration for the credit extended, Applicant hereby agrees to pay all invoices rendered by Rogers Base Company, LLC within 30 days from invoice date, unless other arrangements are agreed to in writing. If at any time for any reason, the undersigned is unable to pay for all purchases when due, and if it becomes necessary for Rogers Base Company, LLC to incur collection costs or institute suit to collect any amount due under this agreement or any portion thereof, the undersigned agrees to pay such additional collection charges and expenses including reasonable attorney fees. The undersigned certifies that he/she is authorized to execute this document and that all statements are true and correct.
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Authorized Signature
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Print Name
*
Date
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MM slash DD slash YYYY
Hidden
Authorized Signature
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