Customer Application

Application Initiated By*
First Last
Email Address*
Hidden
Date*
MM slash DD slash YYYY
Company Trades As*
Corporate Structure*
- Partnership
- Corporation
- Individual
If you are tax-exempt, complete the Tax-Exempt Certificate and return by mail, fax or email.
Partnership
Please fill in the names and addresses of all principal Partners
Partner One's Name*
First Last
Partner One's Address*
Street Address Address Line 2 City State ZIP Code
Partner One's Phone*
Partner Two's Name*
First Last
Partner Two's Address*
Street Address Address Line 2 City State ZIP Code
Partner Two's Phone*
Partner Three's Name
First Last
Partner Three's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Partner Three's Phone
Corporation
Please fill in the name and address of the President and General Manager
President's Name*
First Last
President's Address*
Street Address Address Line 2 City State ZIP Code
President's Home Phone*
General Manager's Name*
First Last
General Manager's Address*
Street Address Address Line 2 City State ZIP Code
General Manager's Phone*
Individual
If individually owned but not incorporated, please fill in the name of the individual owner
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone Number*
Agreement
The undersigned, as an authorized agent for buyer, agrees the buyer shall pay all obligations together with attorney and/or collections fees incurred. If the buyer fails to comply with any of the terms and/or conditions and/or fails to satisfy any obligation of the buyer to the seller; or if the seller with reasonable cause deems the obligation uncollectible without professional and/or legal assistance.
Enter Your Name As Signature*
Title*
Hidden
Date*
MM slash DD slash YYYY
Customer Credit Record
Please complete this form and submit your most recent financial statement (to Wholesome Foods, Inc., 986 South Ox Rd., Edinburg, VA 22824), which we shall hold in strict confidence.
Phone Number*
Billing Address*
Street Address Address Line 2 City State ZIP Code
Delivery Address*
Street Address Address Line 2 City State ZIP Code
Person(s) To Deal With*
Line Of Business*
How Long In Business*
Expected volume, frequency of deliveries, and other comments on probable requirements*
Credit Line Requested*

Our standard credit terms are Net 7 Days from Invoice Date
Credit References
Bank Name*
Bank Address*
Street Address Address Line 2 City State ZIP Code
Bank Phone Number*
Supplier One Name
Supplier One Address
Street Address Address Line 2 City State ZIP Code
Supplier One Phone
Supplier Two Name
Supplier Two Address
Street Address Address Line 2 City State ZIP Code
Supplier Two Phone
Supplier Three Name
Supplier Three Address
Street Address Address Line 2 City State ZIP Code
Supplier Three Phone
Finish
I hearby authorize Wholesome Foods to obtain all pertinet information regarding my credit records necessary in order to process this application. Failure to pay any debt to Wholesome Foods Inc. will result in a charge of 2% per month as well as court costs if needed and attorney fees.
Enter Your Name As Signature*
Hidden
Date*
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

Partnership

Corporation

Individual

Agreement

Customer Credit Record

Credit References

Finish

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