Authorized Service Center Application

This form is for (select one):*
CordobaGuildCordoba & Guild

Contact Name*

Company Name*

Address*

City*

State*

Zip Code*

Telephone*

AP Contact*

Email Address*

CREDIT CARD REFERENCE/INFORMATION

Name*

Address*

Phone*

Type of CC*: VISAAMEXMASTERCARDDISCOVER

CC#*

Expiration Date*


In the event of default on payment, I authorize Cordoba Music Group to charge my credit card on file for the full balance due including any or all late fees.

Yes, I AuthorizeNo, I Do Not Authorize

Your Name*:

Your Email*:


Credit References (USA ONLY)

If applying for terms, you must provide references with net terms, not credit card. Please be advised that the following companies are not able to provide references to us: FENDER, GIBSON, PEAVEY, OR YAMAHA.

Please enter "N/A" if this does not apply to you.

Name*:

Address*:

Phone*:

Account #*:

Fax #*:


Name*:

Address*:

Phone*:

Account #*:

Fax #*:


Name*:

Address*:

Phone*:

Account #*:

Fax #*:


Bank and/or Credit Card Reference Information

Name*:

Address*:

Phone*:

Account #*:


Name*:

Address*:

Phone*:

Account #*:


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