Trotta Tire Application for New COD Account

Application for New COD Account
Business Contact Info
Date

MonthDayYear
Date
Company Name*
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Resale Number*
E-mail*
Type of Business*
In Business Since*
Company Type*

Sole ProprietorshipPartnershipCorporationOther
Ownership Info
Officer/ Principal Name*
Title
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
Spouses Name
Banking Info
Bank Name*
Bank Account #*
Bank Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Bank Phone Number*

Area CodePhone Number
Bank Contact Person
Authorization

(By checking this box you are agreeing to our terms - should you have any questions please contact us)
Agreement and Terms*

I certify that the information provided above is correct and true. I hereby authorize the release of any information pertaining to this application to Trotta Tire & Rubber Co.
Signature of Officer or Principal*

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Authorization