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Dealer Credit Application

"*" indicates required fields

Business Name*

Phone*

Business Address

Street Address City State ZIP

Type of Ownership

Sole Proprietorship

Partnership

Coporation

LLC

Number of Employees

< 5

6 - 9

10+

Federal ID #

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

Principal Owner(s)/Applicant(s)

Full Name*

Title

Home Address

Street Address City State ZIP

Phone*

Email*

SS#

DOB

MM slash DD slash YYYY

Full Name

Title

Home Address

Street Address City State ZIP

Phone

Email

SS#

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

*

Applicant warrants the above information is true and accurate. I/we hereby authorize Rogers Base Company, LLC to contact the references above to evaluate Applicant's credit worthiness. Approved accounts are set up on 30-day terms.

Authorized Signature*

Print Name*

Date*

MM slash DD slash YYYY

24/7 Customer Service:

BreakAway™ Bases
Home Plates
Double First Bases
Pitching Rubbers
Shop Products
Contact

Returns Address:
1600 Vernon St
North Kansas City, MO 64116
Corporate Address:
1525 Sandybrook Ln
Wake Forest, NC 27587
Phone:
1.800.829.7311

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