New Wholesale Account Application

Full Name*

Email Address*

Phone Number*

Company Name*

Company Website*

Shipping Address*

Billing Address (if different than Shipping Address)

Accounts Payable Phone (if different)

Tax ID*

Primary Business*
—Please choose an option—Grocery StoreHealth Food StoreBakeryRestaurantManufacturerContract Manufacturer

Type of Business*
—Please choose an option—Sole ProprietorshipCorporationLimited Liability CompanyPartnershipe-CommOther

Is this business a subsidiary of another Entity?
YesNo

If yes, please list name and address of other operation

Month/Year business was purchased or started by current ownership*

Please include a copy of your resale certificate when submitting this form. (Must be an image below 5MB in size)*