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GENERAL INFORMATION ABOUT THE COMPANY / DATOS GENERALES DE LA EMPRESA
Company RNC
Company Legal Name
Commercial Name
Phone
Fax
Years of Establishment
Company Address
City
Bajos de Hainas
Baní
Barahona
Bayaguana
Boca Chica
Bonao
Constanza
Cotuí
Dajabón
Distrito Nacional
El Seibo
Esperanza
Gaspar Hernández
Guayubín
Hato Mayor
Higuey
Jarabacoa
La Mata
La Romana
La Vega
Las Matas de Farfán
Los Alcarrizos
Mao
Moca
Monte Cristi
Monte Plata
Nagua
Neiba
Pedro Brand
Puerto Plata
Puñal
Salcedo
Samaná
San Antonio de Guerra
San Cristóbal
San Francisco de Macorís
San Ignacio de Sabanate
San José de las Matas
San José de Ocoa
San Juan
San Pedro de Macorís
Santiago de los Caballeros
Santo Domingo Este
Santo Domingo Norte
Santo Domingo Oeste
Sosúa
Tamboril
Tenares
Villa Altagracia
Villa Bisonó
villa González
Villa Hermosa
Villa Riva
Yamasá
Otro
State / Province
Azua
Bahoruco
Barahona
Dajabón
Distrito Nacional
Duarte
El Seybo
Elías Piña
Espaillat
Hato Mayor
Hermanas Mirabal
Independencia
La Altagracia
La Romana
La Vega
María Trinidad Sánchez
Monseñor Nouel
Monte Plata
Montecristi
Pedernales
Peravia
Puerto Plata
Samaná
San Cristóbal
San José De Ocoa
San Juan
San Pedro De Macorís
Sánchez Ramírez
Santiago
Santiago Rodríguez
Santo Domingo
Valverde
Otro
ZIP Code
Corporate Office Address is Different
Delivery Address
City
Bajos de Hainas
Baní
Barahona
Bayaguana
Boca Chica
Bonao
Constanza
Cotuí
Dajabón
Distrito Nacional
El Seibo
Esperanza
Gaspar Hernández
Guayubín
Hato Mayor
Higuey
Jarabacoa
La Mata
La Romana
La Vega
Las Matas de Farfán
Los Alcarrizos
Mao
Moca
Monte Cristi
Monte Plata
Nagua
Neiba
Pedro Brand
Puerto Plata
Puñal
Salcedo
Samaná
San Antonio de Guerra
San Cristóbal
San Francisco de Macorís
San Ignacio de Sabanate
San José de las Matas
San José de Ocoa
San Juan
San Pedro de Macorís
Santiago de los Caballeros
Santo Domingo Este
Santo Domingo Norte
Santo Domingo Oeste
Sosúa
Tamboril
Tenares
Villa Altagracia
Villa Bisonó
villa González
Villa Hermosa
Villa Riva
Yamasá
Otro
State / Province
Azua
Bahoruco
Barahona
Dajabón
Distrito Nacional
Duarte
El Seybo
Elías Piña
Espaillat
Hato Mayor
Hermanas Mirabal
Independencia
La Altagracia
La Romana
La Vega
María Trinidad Sánchez
Monseñor Nouel
Monte Plata
Montecristi
Pedernales
Peravia
Puerto Plata
Samaná
San Cristóbal
San José De Ocoa
San Juan
San Pedro De Macorís
Sánchez Ramírez
Santiago
Santiago Rodríguez
Santo Domingo
Valverde
Otro
ZIP Code
Delivery Address is Different
Delivery Address
City
Bajos de Hainas
Baní
Barahona
Bayaguana
Boca Chica
Bonao
Constanza
Cotuí
Dajabón
Distrito Nacional
El Seibo
Esperanza
Gaspar Hernández
Guayubín
Hato Mayor
Higuey
Jarabacoa
La Mata
La Romana
La Vega
Las Matas de Farfán
Los Alcarrizos
Mao
Moca
Monte Cristi
Monte Plata
Nagua
Neiba
Pedro Brand
Puerto Plata
Puñal
Salcedo
Samaná
San Antonio de Guerra
San Cristóbal
San Francisco de Macorís
San Ignacio de Sabanate
San José de las Matas
San José de Ocoa
San Juan
San Pedro de Macorís
Santiago de los Caballeros
Santo Domingo Este
Santo Domingo Norte
Santo Domingo Oeste
Sosúa
Tamboril
Tenares
Villa Altagracia
Villa Bisonó
villa González
Villa Hermosa
Villa Riva
Yamasá
Otro
State / Province
Azua
Bahoruco
Barahona
Dajabón
Distrito Nacional
Duarte
El Seybo
Elías Piña
Espaillat
Hato Mayor
Hermanas Mirabal
Independencia
La Altagracia
La Romana
La Vega
María Trinidad Sánchez
Monseñor Nouel
Monte Plata
Montecristi
Pedernales
Peravia
Puerto Plata
Samaná
San Cristóbal
San José De Ocoa
San Juan
San Pedro De Macorís
Sánchez Ramírez
Santiago
Santiago Rodríguez
Santo Domingo
Valverde
Otro
ZIP Code
COMPANY INFORMATION / CARACTERÍSTICAS DE LA EMPRESA
Llenar únicamente para solicitudes de crédito
Shop / Local
Own / Propio
Rented / Alquilado
Other / Otro
Monthly Rent Amount
Store Name or Owner
Manager Name
Purchasing Manager Name
Shopping Day / Día de Compras
Monday / Lunes
Tuesday / Martes
Wednesday / Miércoles
Thursday / Jueves
Friday / Viernes
No Specific Day / Sin Día Específico
Name of Payment Officer
Shopping Day / Día de Compras
Monday / Lunes
Tuesday / Martes
Wednesday / Miércoles
Thursday / Jueves
Friday / Viernes
No Specific Day / Sin Día Específico
Payment Method / Forma de Pago
Cash / Efectivo
Bank Check / Cheque
Transfer / Transferencia
Currency
RD$
USD
Special Exemption / Exoneración Especial
Gubernamental
Zona Franca
Otros
BUSINESS REFERENCES / REFERENCIAS COMERCIALES
Detalles de referencias
Reference # 1*
Company Name
Years of Business Relationship
Contact Name
Phone
Email
Add Another Reference
Yes / Si
No
Company Name
Years of Business Relationship
Contact Name
Phone
Email
Add Another Reference
Yes / Si
No
Company Name
Years of Business Relationship
Contact Name
Phone
Email
I authorize Hizamar investments to validate the information specified in this form. / Autorizo a Inversiones Hizamar a validar las informaciones especificadas en este formulario.
Stamp Image / Imagen de Sello
ATTACHED / ANEXO REGISTRO MERCANTIL, ESTATUTOS LEGALES, ACTA DE ASAMBLEA, CERTIFICACIÓN DEL RNC
EMAIL SENDER FORM
APPLICATION DATE
Send
