Dealer Information

    (in email "Sales Dealer Application - Next Steps")

    Administrative Contact

    Operations Manager Contact

    Sales Manager Contact

    Company Specifics

    Insurance Information

    Solanta Corp d/b/a Solanta

    141 Flushing Ave,

    Building 77, Suite 505

    Brooklyn, NY 11205

    General Liability *
    Workers Compensation


    'Solanta is covered as additional insurance on the above listed policies' on each certificate.

    Trade References

    1st Creditor

    2nd Creditor

    3rd Creditor

    Bank Reference


    *all who have 10% or greater steak must be listed

    Stakeholder 1

    Stakeholder 2

    Stakeholder 3

    Stakeholder 4

    Dealer Declaration

    I (we) agree that the Contractor (Solanta Corp) may procure or verify credit information of the dealer, principals, or account holders from third parties such as other businesses, creditors, or third party reporting agencies. I (we) agree to the Contractor exchanging information about our obligations with references and other business or credit reporting agencies. I (we) further understand that use of a photocopy of this form may be necessary to verify one or more of my (our) credit references. I (we) authorize the use and request of such a photocopy by honored fully. I (we) hereby expressly and directly grant the Contractor permission to transmit to Dealer any type of facsimile or email, including such that advertise the Contractor's products or services to the facsimile number and email provided above.

    This authorization shall remain in effect until written notice is given to terminate such Agreement. Please make copies of all documents for your records. I (we) submit the above information as being true, complete and accurate as of the date shown.