DEALER APPLICATION
Company Name
Business Name
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Store number
Ordering Person Cell Phone Number
*
Cell phone
E-mail
*
example@example.com
State of Organization
EIN Number or primary applicant SSN
*
State Tax Exempt Certificate
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Accounting Contact Info
First Name
Last Name
Accounting Email
example@example.com
Please give reference of current manufactures you do business with
Company Name
Contact Person
Contact Number
1
2
The undersigned hereby certifies that the above is true and complete to the best of his/her/their knowledge, and that any credit granted will be used from the purchase of agriculture products and services. Information provided or authorized to be disclosed to Winter Livestock and Feed LLC will be used solely for the purpose of establishing and monitoring credit and collecting credit extended to you.
*
Direct Deposit Authorization (ACH)ACH will be drafted for entire order 3 day after of shipment/pick-up
Name(s) on Bank Account (business name if used)
*
Routing Number
*
Account Number
*
Bank Name
*
Bank Phone Number
*
Type of Bank Account
*
Please Select
Personal Checking
Personal Savings
Business Checking
Business Savings
Other
We authorize Winter Livestock & Feed LLC to withdraw funds equal to my invoice amount. This authorization is to remain in force as long as our company places orders with Winter Livestock and Feed LLC.
*
Yes
Signature
*
Please verify that you are human
*
Submit
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