Rogada Services
Rogada Services
   
   
   
 
     
BUSINESS INFORMATION   DESCRIPTION OF BUSINESS
     
Name of Business:   Required   # of Employees:  
Legal (If Different):     Dealer License #:   Required
Business Address:   Required   Type of Business:  
City:   Required   In Business Since:  
State:     Business Phone:  
Zip Code:   RequiredInvalid   Parent Compnay:  
Mobile Phone:     Years in Business:  
Email Address   RequiredInvalid        
COMPANY PRINCIPAL RESPONSIBLE FOR BUSINESS TRANSACTIONS
     
Name:   Required   Name:  
Title:   Required   Title  
Address:   Required   Address:  
Phone   RequiredInvalid   Phone  
DL #:   Required   DL #:  
             
     
BANK REFERENCE
             
Name of Bank:   RequiredInvalid   Branch:   Required
Address:   RequiredInvalid   Name to Contact:   Required
Phone Number:   RequiredInvalidInvalid   Checking Account #:   A value is required.
     
TRADE REFERENCE
     
Company Name:   Required   Company Name:  
Contact Name:   Required   Contact Name:  
Phone Number:   RequiredInvalid   Phone Number:  
Trading Since:   Required   Trading Since:  
 
Confirmation of information accuracy and release of authority to verify

I hereby certify that the information in this credit application is correct. the information included in this application is for use by Rogada Services in determining the amount and conditions of a business relationship. I understand that Rogada Services may also utilize the other sources of credit which it considers necessary in making this Determination. further, I hereby authorize the bank and trade references listed in this application to release the information that may be necessary to assist Rogada Services in establishing a business relationship. In completing this form your IP address is logged for security.

 
     
Do you Agree ? I agree to the terms   I don't agree to the terms
     
Authorized Name:   Required   Title   Required Date: RequiredInvalid
     
Policy Statement: Initial sales from new buyers will not be processed unless accompanied by the above requested information.
     
 
     
 
     
   
E-mail us at: info@rogadaservices.com
   
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