Rotary Dealer Application

Become a Dealer

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Business Information

Submitted By*

Business Name*

Business Owner's Name*

Your E-Mail Address*Verify Your Email*

Business Phone #*

Business Fax #

Date Business was Established*

Business Mailing Address

Street Address*

City*

State*

County*

Zip*

Shipping address is the same as mailing address

Business Shipping Address

Street Address

City

State

County

Zip

Credit Application

Required only if "Open Account" was selected above

Dun & Bradstreet #

Owner's Name*

Owner's Home Address*

City*

State*

Zip*

Home Telephone #*

Is there a Second Owner?

Second Owner's Name

Home Address

City

State

Zip

Home Telephone #

Credit References

Please list 3 Credit References and 1 bank reference.
(All four are REQUIRED in full)

Credit Reference (1) Name*

Account #

Contact*

Street Address*

City*

State*

Zip*

Telephone #*

Fax Number

Credit Reference (2) Name*

Account #

Contact*

Street Address*

City*

State*

Zip*

Telephone #*

Fax Number

Credit Reference (3) Name*

Account #

Contact*

Street Address*

City*

State*

Zip*

Telephone #*

Fax Number

Bank Reference Name*

Contact*

Street Address*

City*

State*

Zip*

Telephone #*

Fax Number*

Owner's Signature*

Date: 10/23/2017

Become a Dealer