Rotary Dealer Application

City*

State*

County*

Zip*

Shipping address is the same as mailing address

City

State

County

Zip

Sales Tax Certificate

Do you accept backorders?*
YesNo

Payment Terms
Open AccountCredit Card Only

If Open Account is approved, would you like to receive your Invoices/Statements via email?
e-Invoice email address:e-Invoice contact name:e-Statement email address:e-Statement contact name:

Additional Remarks:

Owner's Home Address*

Is there a Second Owner?

Bank Reference Name*

Contact*

Telephone #*

Fax Number*

Bank Reference Account #*

Credit Reference (1) Name

Account #

Contact

Telephone #

Fax Number

Credit Reference (2) Name

Account #

Contact

Telephone #

Fax Number

Credit Reference (3) Name

Account #

Contact

Telephone #

Fax Number

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of First Owner*

Date: 04/29/2024

Signature of Second Owner*

Date: 04/29/2024

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Business Information

Business Mailing Address

Business Shipping Address

Business Permit Information

Credit Application

Credit References