Customer Information

First Name *

Last Name *

Phone Number *

Email *

Terms

Desired Terms *

Credit Amount Requested *

Bank Reference

Bank Name *

Bank Manager or Contact *

Phone Number *

Email *

Bank Account Number

Branch Transit Number (Routing Number)

If you prefer to not enter your bank information call (877) 874-2334 with the information.

Billing Information

First Name *

Last Name *

Company Name *

Address *

Town/City *

State/Province *

Zip/Postal Code *

Country *

Accounts Payable

Accounts Payable Contact *

Accounts Payable Email *

Electronic Invoices *

Paper Invoices *

Additional Billing Requirements/Comments

Account Terms And Conditions

Company hereby certifies that information furnished in this application is current and accurate. The term of this agreement shall be for one (1) year period; provided, however, that either party may terminate this agreement on 30 days written notice to the other party. If the parties continue to conduct business after termination, the provisions of this agreement will continue to apply.

Our payment receiving terms are DUE UPON RECEIPT unless credit is issued to company.

Company affirms that it is solvent, is not currently a party to any bankruptcy proceeding, is not being dissolved or otherwise liquidating its assets and can satisfy all financial obligations. Company affirms that there are no open judgments, suits, or liens against Company.

FEES - A $25.00 re-billing fee or finance charge of 2% per month (24% annum) are added to accounts 7 days or more days past due.

If Rocky Mountain BioAg® (RMBA®) utilizes the services of a collection agency or attorney to collect any amounts due, company agrees to pay ALL associated collection costs, attorney fees, and court costs including lodging, meals and travel.

Company will promptly notify RMBA® of any change in ownership.

By selecting the READ and AGREE boxes below, company acknowledges that the individual executing this agreement has authority to do so and further authorizes RMBA® to contact each and every credit/bank reference provided if terms are desired.

Company understands that RMBA® is a distributor who supplies products from third party manufacturers.

The district/county courts located in Montrose County, Colorado shall have exclusive and irrevocable jurisdiction and shall be the exclusive venue with respect to any claim, counterclaim, or dispute arising in connection with any transactions or other business between Rocky Mountain BioAg® and company.

In the event company is negligent or breaches the terms of this agreement and there is a resulting claim, lawsuit or damages asserted against RMBA®, it agrees to indemnify, defend and hold RMBA® harmless to the fullest extent of the law.

I Have Read The Account Terms And Conditions *

READ

By selecting the READ box, company acknowledges that the individual executing this agreement has authority to do so.

I Agree To The Account Terms And Conditions *

AGREE

By selecting the AGREE box, company acknowledges that the individual executing this agreement has authority to do so.

First Name *

Last Name *

Date Signed *

Account Application

Customer Information

Company Information

Terms

Bank Reference

Bank Reference

Billing Information

Accounts Payable

Shipping Address Information

Freight Delivery Information

Freight Delivery Terms and Conditions

Account Terms And Conditions

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