Dealer Application

UserName *
Name Of Company/Corporate Title *
DBA *
Street Address *
Suite/unit
City * State * Zip Code *
Phone Number * Fax Number
Email Address *
Resale Tax Certificate Number *
Date Business Started *
Type of Business
Full Name of Owner or Authorized Officer *
Home Address *
Home Phone *
Person/Persons authorized to make purchases on this account *
Website *

Trade References

Name Address Phone Fax

Bank Reference

Name of Bank *
Contact Person *
Street Address *
City * State * Zip Code *
Phone Number * Fax Number *
Account Number *

Electronic Signiture

By typing your name below, you agree to Rolls Co. Payment Delinquency Policy

Electronic Signiture *
Title *

Enter the letters you see in the above image.

* required

Payment Delinquency - Buyer agrees to pay Seller an interest rate of 1.5% per month on all invoices over 30 days. There will be a loss of all discounts on invoices over 30 days past due. Buyer assumes responsibility to know and follow all Rolls policies as stated on the Rolls Dealer Price List.