The Rogue Creamery Wholesale Customer Set

The Rogue Creamery
311 N. Front Street, Central Point, OR 97502
T: 541.665.1155 F: 541.665.4937
Wholesale Customer Set-Up Form
Must be returned before shipment of first order. Complete this form entirely with all 3 references and complete addresses
Name/Address
Last Name
First Name
Middle Initial
Title
Name of Business
Feferal Tax I.D.
Mailing Address:
Phone:
Physical Address
Fax:
Website:
Email:
Company Information
Type of Business
In Business Since:
Legal Form Under Which Business Operates (Corporation,, Partnership, Proprietorship, Other )
If Division/Subsidiary, Name of Parent Company:
In Business Since:
Name of Company Principal Responsible for Business Transactions:
Title:
Address:
Phone:
Bank Reference
Institution Name:
Address:
Checking Account #:
Phone:
Institution Name:
Address:
Fax:
Savings Account #:
Phone:
Fax:
Trade Reference
Company Name and Contact:
Address:
Account Since:
Phone:
Company Name and Contact:
Address:
Account Since:
Phone:
Company Name and Contact:
Address:
Account Since:
Phone:
Credit Limit:
Fax:
Credit Limit:
Fax:
Credit Limit:
Fax:
I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is
to be used to determine the amount and conditions of the credit to be extended. Furthermore, I hereby authorize the financial institutions listed in this
credit application to release necessary information to the company for which credit is being applied for in order to verify the information contained
herein. The undersigned also agrees that in the event the above account defaults on and all debts owed to The Rogue Creamery, he/she will
personally assume the said debts, including any and all collections fees and interest, at the rate of 1.5% per month on the unpaid balance.
Signature of Officer/Owner:
Date:
Printed Name:
Title: