Rogada Services
Rogada Services
   
   
   
 
     
BUSINESS INFORMATION   DESCRIPTION OF BUSINESS
     
Name of Business:     # of Employees:  
Legal (If Different):     Dealer License #:  
Business Address:     Type of Business:  
City:     In Business Since:  
State:       Business Phone:  
Zip Code:     Parent Compnay:  
Mobile Phone:     Years in Business:  
Email Address          
COMPANY PRINCIPAL RESPONSIBLE FOR BUSINESS TRANSACTIONS
     
Name:     Name:  
Title:     Title  
Address:     Address:  
Phone     Phone  
DL #:     DL #:  
             
     
BANK REFERENCE
             
Name of Bank:     Branch:  
Address:     Name to Contact:  
Phone Number:     Checking Account #:  
     
TRADE REFERENCE
     
Company Name:     Company Name:  
Contact Name:     Contact Name:  
Phone Number:     Phone Number:  
Trading Since:     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.

 
     
I agree to the terms   I don't agree to the terms
     
Authorized Name:     Title   Date:
     
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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