Personal Information

Are you a U.S. Citizen?
Have you established credit?

Address and Phone

$ .00
Phone Number:
- -
Name Phone Billed Under:

By submitting, I consent to: 1) be contacted about my account through any contact information I provide, including cell phone numbers, even if I am charged under my phone plan; and 2) the use of any automatic telephone dialing system and/or a prerecorded message when contacted.





Social Security Number:
- -
Date of Birth (mm/dd/yyyy):
/ /

Name of Nearest Relative Not Living With You:


Phone Number:
- -

Employment Information

*If, yes, please provide the name of your company in the employer/source of income field.


Phone Number:
- -

Income and History

$ .00
Length of Employment/Source of Income:
*Total Monthly Income includes income from a job, including full time, part time, or seasonal jobs or from self employment and includes bonuses, tips and commissions. It includes interest or dividends, rental income, retirement income or public assistance, as well as profit from self employment. It includes shared income, which is money from somebody else that is regularly deposited into your account or a joint account that person shares with you. If you are 21 or older, you may also include income from others if you can use that income to pay your bills. Alimony, child support or separate maintenance need not be revealed if you do not wish to rely on it to obtain credit.

If you've been with your current employer for less than 1 year, please
fill out the following shaded section about your previous employment:



Consent to Electronic Communications

Print Print

Introduction. This document establishes your consent to communicate with us electronically. Please read this document carefully and retain a copy for your records. The words we, us, and our mean Sterling Jewelers Inc. d/b/a Rogers Jewelers. The word you means the individual or individuals applying for a Rogers Jewelers credit card account. The word Disclosures means the communications set forth in the Scope of Consent paragraph below.

Consent to Receipt of Electronic Disclosures. By indicating your agreement below, you indicate that you are able to receive our Disclosures electronically and that you consent to receiving them electronically. Such Disclosures shall be considered to be in writing and in a form you can keep for the purposes of state and federal law. Furthermore, any method that you use to indicate your assent during the application process shall be considered an electronic signature.

Scope of Consent. Your consent applies to the receipt of all legal and/or regulatory disclosures associated with applying for a credit card account with us. This includes, but is not limited to, the following communications:

  • The Retail Installment Credit Agreement governing your account if you are approved for credit.
  • Our initial privacy notice for your Rogers Jewelers credit card account.

Your consent does not apply to any communication that occurs after we approve or deny your application for credit.

Hardware and Software Requirements. To access, view, and retain Disclosures that we provide you, you must have:

  • A connection to the Internet.
  • A current version of an Internet browser which supports HTML and SSL encryption.
  • Your browser settings must have cookies and java script enabled.
  • A means to print or store notices and information through your browser software.
  • The hardware and software necessary to operate the items above.

Paper Copies. Upon request, we will provide you with paper copies of the Disclosures. You may make such a request by calling us at1-800-877-3616. There is no charge for paper copies.

Withdrawing Consent. You may withdraw your consent by discontinuing the application process at any time before you submit your application. However, if your consent is withdrawn, you cannot apply for a Rogers Jewelers credit card account online. You may also apply in person at any Rogers Jewelers store.

Updating Your Contact Information. If any contact information you provide us changes, please call us at 1-800-877-3616 so that we may update our records.

Federal Law. Your consent is being provided in connection with a transaction affecting interstate commerce and is subject to the federal Electronic Signatures in Global and National Commerce Act. The Act shall apply to the fullest extent possible in order to validate our ability to conduct business with you electronically.

* * * *

Separate Privacy disclosures apply to the Rogers Jewelers Credit Card Account.

Passwords should be a minimum of 8 characters long and contain at least one letter and one number.

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