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

Company Name:*

Upload Pre-Filled Credit Application (If Applicable)

C&C Sales Person*

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?*

: HH

MM

Time you Do Not Accept Deliveries?*

: HH

MM

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*

Phone

This field is for validation purposes and should be left unchanged.

New Customer Credit Application Form

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