RADAK LLC

3277 Pine Orchard Ln Unit # 3

Ellicott City, MD 21042

Dealer Application Form

 

Business Information

FULL NAME OF BUSINESS:   ______________________________________________

DBA NAME (If Applicable):  ______________________________________________

Owner’s Name: ____________________________________________

Business Form:  Corporation   Partnership 

Federal Tax ID#: ______________  Sales Tax Reg. #: _______________ State: _____

Type of Business:  Retail Store  Web Based   Other  _______________________

Years in  Business: _____

Billing Business Address: _______________________________________

City: ___________________     State: ________  Zip Code: ________

Phone: _________________ Email address:  ______________________

Website: ___________________________

Shipping Address: (if different than above) __________________________________

City: ___________________     State: ________  Zip Code: ________

 

References in the Hobby Industry

Name: __________________ Account #: _____________ Phone: ________________

Name: __________________ Account #: _____________ Phone: ________________

Name: __________________ Account #: _____________ Phone: ________________ 

 

Bank Reference

Bank Name: _______________________   Bank Phone: ______________________

Street address: ____________________    Checking Account: _________________

City/State/Zip: ____________________   Officer or Contact: _________________

 

Payment Information

Credit Card Type:  VISA   Master Card   AMEX

Credit Card #: _________________________________________________________

Expiration Date: ______________  CVV code: ___________

Credit Cardholder Billing Address: __________________________________________

City: _____________________  State: ______________  Zip Code ___________

Cardholder Name: ____________________________  Signature: _________________

  

Retail Agriment

This Bussiness aplication is given for the purpouse of opening an account with RADAK LLC.

The information containing herein is correct, completed and true. 

Print Name: ____________________  Signature: _______________ Date: ____________