CUSTOMER REGISTRATION FORM
FARMERS WHOLESALE MARKET
NAME:
*
First Name
Last Name
ADDRESS:
*
Street Address
Street Address Line 2
City
State
Zip Code
BUSINESS NAME:
*
BUSINESS ADDRESS:
*
Street Address
Street Address Line 2
City
State
Zip Code
CONTACT INFORMATION
Home Number
*
Please enter a valid phone number.
Mobile Number
*
Please enter a valid phone number.
Business Number
*
Please enter a valid phone number.
E-mail
*
example@example.com
What commodities, quantities and how frequent would you be interested in purchasing at the Farmers Wholesale Market (e.g. Cucumbers 100 lbs. weekly, Pepper Sauce 60 bottles monthly)
*
Where are you currently purchasing your agricultural commodities?
THANK YOU!
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