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Customer Application Form
Please fill out the following form and submit
Customer Information
Legal
Please check one
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CORPORATION
LIMITED LIABILITY COMPANY
PARTNERSHIP
SOLE PROPRIETOR
Full Legal Business Name
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DBA (if applicable)
Billing Address
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City
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State
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Zip Code
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List Full Names and Addresses of Officers, Partners/Propietor(s)
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Tax ID (EIN/SSN)
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State Sales Tax Number
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Upload A Copy of Your State Sales License
Registered as
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Wholesaler
Retailer
Manufacturer
Non-profit
Other
Other
How would you descripe your business?
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Market
Grocery Store
Restaurant
-Other
-Other
Accounts Payable
AP Name
*
AP Phone
*
AP Email Address
*
Preferred Method of Payment
*
Cash (COD)
Check (15 days)
Credit Card (7 days) 2.99% processing fee
ACH (7 days)
Delivery
Delivery Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Years At This Address
*
Delivery Instructions
Contact Information
Contact 1
Job Position
*
Chef
Kitchen Manager
Buyer
First Name
*
Last Name
*
Phone Number
*
Email Address
*
Contact 2
Job Position
*
Owner
Co-owner
First Name
*
Last Name
*
Phone Number
*
Email Address
*
SALES TAX EXEMPTION MULTI-JURISDICTION
Issued to: Farmstead Foods, LLC 16182 Mount Zion Road Benton, IL. 62812. This is to certify that merchandise purchased by the undersigned from Farmstead Foods, LLC, for use in their operation has the following State Sales Use Tax Status.
I certify that the following is true
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Merchandise sold to the public, on which we collect and remit Retail Sales Tax. Items Exempt: FOOD PRODUCTS
Purchaser understands and agrees that if the purchase made under this certificate is used other than stated above for any purchase which would not exempt the sale within any of the designated jurisdictions, he becomes liable for the tax thereon and will pay such tax directly to the appropriate tax jurisdiction.
This certificate covers all future orders and is deemed valid until canceled by us in writing or as determined by state law. This certificate is considered valid if all requested information is provided and is correct.
Under penalties of perjury, I affirm that the information provided on this form is true and correct as to every material matter.
Preparer's Full Name
*
Title
*
Date
*
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Signature
*
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Sourcing local farm fresh products