RD 1944-5 Rurl Development Manufactured Housing Dealer-Contractor

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Form RD 1944-5
(Rev. 12/98)

FORM APPROVED
OMB NO. 0575-0172

USDA - Rural Development

RURAL DEVELOPMENT MANUFACTURED HOUSING

DEALER-CONTRACTOR APPLICATION

Date

TO: (Rural Development)

As provided in 7 CFR Part 3550, this application is submitted for your approval as a Dealer-Contractor.
Phone Number

DUNS #

Tax Identification #
Trade Name

Ownership
SOLE
PROPRIETORSHIP
PARTNERSHIP

Date Business Established

Number and Street

CORPORATION

City, Zone, State

Years at Present
Address

Previous Address

Years at Previous
Address

Number of Sales
Personnel

Date Financial Statement

Identify Sales Personnel
on Separate Attached Sheet

Type of Business (General Contracting, Lumber Yard, Heating, etc.)

IF NOT A SOLE PARTNERSHIP, IDENTIFY PRINCIPALS
Title

Name

Home Address

1.
2.
3.
EMPLOYMENT HISTORY OF PRINCIPALS FOR PAST TEN YEARS (If more space is needed, use an attached sheet)
Names and Addresses of Employers

Name of Principal, Position, and Dates Employed

Type of Business

1.

2.

3.

Bank of Deposit
Dates

CREDIT REFERENCES

From

Address

Name

Year

To

Year

TRADE REFERENCES: (NAME PRESENT AND PREVIOUS SUPPLIERS OF MAJOR PRODUCTS)
Names

Address

If any work is subcontracted, give type of work and trade name of subcontractor.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0575-0172. The time required to complete this information collection is estimated to average 30 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

Form RD 1944-5 (Rev. 12/98)

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No. of Branches

Sales Area
Addresses of Branches

Describe any Guaranty Given Buyers

I(we) hereby understand that I(we) am (are) fully responsible for the Rural Housing activity of all my(our) sales personnel, that ethical and proper selling practices will
be followed, and that immediate attention will be given to all complaints involving materials, workmanship or sales representations. I(we) hereby certify that the above
statements are true. I(we) understand this application shall remain the property of Rural Development.
Trade Name

By: (Name and Title)

I/We hereby authorize the Rural Housing Service (RHS), or its successor, to order an individual credit report for each principal, or for the sole proprietor, referred to on
the previous page, on a recurring basis as may be necessary, until such time as the individual notifies RHS to the contrary.

Signature of Individual Principal or
Sole Proprietor

Social Security Number

Signature of Individual Principal or
Sole Proprietor

Social Security Number

Signature of Individual Principal or
Sole Proprietor

Social Security Number

Signature of Individual Principal or
Sole Proprietor

Social Security Number

WARNING: Section 1001 of Title 18, United States Code provides: ''whoever, in any matter within jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals or covers up by any
trick, scheme, or device a material fact, or makes any false, fictitious or fraudulent statements or representations, or makes or uses any false writing or document knowing the same to contain any false, fictitious or
fraudulent statement or entry, shall be fined under this title or imprisoned not more than five years or both.''

FOR USE OF DEALER-CONTRACTOR FOR SUPPLYING ADDITIONAL INFORMATION

FOR USE BY RURAL DEVELOPMENT
CREDIT REPORT(S)
ATTACHED
REPORTED DATED:

(

)

TRADE REFERENCES CHECKED

CREDIT REFERENCE(S) CHECKED

SALES LITERATURE
RECEIVED

COPY OF CONTRACT OR
SALES AGREEMENT REC'D
Date Inspected

Place of Business Inspected by: (Name and Title)
Remarks:

The dealer-contractor whose application appears hereon has been approved after such investigations as we consider necessary to establish that the
dealer-contractor is reliable, financially responsible and qualified to perform satisfactorily the work to be financed and to extend proper service to the
customer.
Dealer-Contractor Approved (Date)

By: (Name and Title)

Form RD 1944-5
(REVERSE)

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