New Customer Electronic Credit Application – Midwest's Premiere Produce Distributor

New Customer Credit Application Form

Company Name:*
Upload Pre-Filled Credit Application (If Applicable)
Max. file size: 200 MB.
C&C Sales Person*
Accounts Payable Contact*
Accounts Payable Contact*
Accounts Payable Contact Email*
Accounts Payable Phone Number*
Accounts Payable Fax Number*
Address*
Street Address City State ZIP Code
What time do you Start Accepting Deliveries?*

: Hours

Minutes
Time you Do Not Accept Deliveries?*

: Hours

Minutes
Preferred Delivery Window?*
Do you accept Key Drops?*
Billing Address if Different than Above*
Street Address City State ZIP Code
Type of Ownership?*
- Partnership
- Individual
- Corporation
Tax Exempt #:*
Federal Tax ID#*
Business Reference #1 (Other than Soft Drink Companies)*
Street Address Address Line 2 City State ZIP Code
Business Reference #2 (Other than Soft Drink Companies)*
Street Address Address Line 2 City State ZIP Code
Business Reference #3 (Other than Soft Drink Companies)*
Street Address Address Line 2 City State ZIP Code
Business Reference #4 (Other than Soft Drink Companies)*
Street Address Address Line 2 City State ZIP Code
Reference Check Consent*
I agree to the below terms
I hereby give authorization to C&C Produce to verify payment and account history with the vendors I have listed above. All information gathered will be used only to the extent of establishing a credit account and will be held in strict confidence. I also acknowledge that I am authorized to complete the attached credit application on behalf of my company. Our Terms are 10 (Days) Unless Otherwise Arranged.
Name
First Last
Title
Phone*
Email
This field is for validation purposes and should be left unchanged.

New Customer Credit Application Form

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