Supplier Application

Name*

First NameLast Name
Title*
Email*
example@example.com
Phone*

Area CodePhone Number

Company Profile
Company Name*
Web Address
Line Names
ASI Number
PPAI Number
UPIC
Federal ID Number*
Minority Certified*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
General Phone

Area CodePhone Number
Fax

Area CodePhone Number
General Email
example@example.com

Payment Preferences
Payment Preference

Credit CardACHCheck
Supplier is not authorized to assess fees for credit card payments.
ACH Coordinator Name

First NameLast Name
ACH Coordinator Phone

Area CodePhone Number
Remittance Email Address
example@example.com
ABA Routing
Account Number
Credit Limit
ACH Discount

Your Anticipated Commitment to RR Members
Column Pricing*
Suggested EQP (or better) 1st column minimum (or less)
Volume Rebate*
Recommended 3% to 7% from $0.01
Volume Achievement Bonus
Terms and/or Prompt Pay Discount*
Suggested Terms are 3/15, net 45
Self Promo
Management Engagement
Strongly suggested Sales reporting and yearly calls with upper management as required