Commercial Billing Application, for our commercial customers.

General

Company Name


Tax Identification Number \ EIN


Owner Name


State Incorporated In (If Applicable)


Years in business


Location

Business Address


City


State


Zip Code


Contact Info

Phone Number


Fax Number


E-Mail Address


Credit References

Name		Address
Phone		City
Fax		State
E-Mail		Zip Code

Name		Address
Phone		City
Fax		State
E-Mail		Zip Code

Name		Address
Phone		City
Fax		State
E-Mail		Zip Code

Validation

I certify that the information given is true, correct and complete and is given for the purpose of obtaining credit, and Rome Leasing, Inc., and any other creditor or prospective of the undersigned or say agency employed by you or any of them are authorized to make investigations concerning the undersigned or concerning the above information and to disclose to each other the information set forth above and the results of each investigation.

Authorized Signature I Agree

I acknowledge that credit privileges, if granted, may be withdrawn at any time. Payments are due within 10 days of receipt of invoice. Balances over 30 days are subject to interest at 1.5% of amount due. I agree to pay any and all costs of collection including reasonable attorney's fees incurred by Rome Leasing, Inc. in collecting any overdue account.

Authorized Signature I Agree