Dealer Application Form

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: ________

Name: __________________ Account #: _____________ Phone: ________________

Bank Name: _______________________ Bank Phone: ______________________

Street address: ____________________ Checking Account: _________________

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

Credit Card Type: VISA Master Card AMEX

Credit Card #: _________________________________________________________

Expiration Date: ______________ CVV code: ___________

Credit Cardholder Billing Address: __________________________________________

City: _____________________ State: ______________ Zip Code ___________

Cardholder Name: ____________________________ Signature: _________________

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: ____________