Pitco Foods New Account Application

Corporate Office
567 Cinnabar St.
San Jose, CA 95110
P (408) 282-2200
F (408) 282-9711

Cash and Carry and Distribution Centers
1800 Merced St., San Leandro, CA 94577
385 Valley Drive, Brisbane, CA 94005
3575 Ramos Dr, W. Sacramento, CA 95691
567 Cinnabar St., San Jose, CA 95110

NEW ACCOUNT APPLICATION

BUSINESS INFORMATION

Name of Business*

Check Type:*

CorporationPartnershipIndividual

Name of Owner*

Name of Partner

Business Street Address*

City*

State*

Zip*

Sellers Permit #*

Select One*

Cash and CarryAt-Store Delivery-must use ACH Payment

Phone Number*

Cigarette Lic. #

Time Open*

Time Close*

E-mail*

At-Store Delivery Request*

YesNo

Does your store have a receiving dock door*

YesNo

Receiving Hours*

PERSONAL INFORMATION

First Name*

Last Name*

Street Address*

City*

State*

Zip*

CA or NV License or ID #*

Cell Number*

If you have other stores or accounts at Pitco already, please list each account number here

BUSINESS BANKING INFORMATION

Name of Bank*

Account #*

Company Name*

PACG5543PD

I (WE) hereby authorize PACIFIC GROSERVICE Dba: PITCOFOODS, hereinafter called COMPANY, to initiate debit entries to my (our)

Choose type of account*

CheckingSavings Account

Indicated below at the depository named below, hereinafter called DEPOSITORY, to credit the Same to such account.

Bank Name*

Routing Number*

Account No.*

This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.

Name(s)*

Driver License ID Number*

Date

Signature*

Partner Signature

Customer Email*

example@example.com

NOTE: ALL WRITTEN DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.

REQUIRED UPLOADS:

• ABC (Alcohol Beverage Control Resale License)
• Cigarette and Retailers Tobacco License (non-required)
• State Board of Equalization Sellers Permit
• Drivers License
• Voided Check

Note: if Nevada customer, must upload License from the Department of Taxation

ALL ARE REQUIRED TO COMPLETE APPLICATION

Click Here and Upload*

Browse Files

TERMS

• There will be a $50.00 charge on your account for each returned check for insufficient funds • Merchandise purchased with tax exemption, will be solely for resale purposes. • In consideration of purchasing products from Pitco Foods, the undersigned agrees to pay any and all debts on demand/within terms to. • Futhermore, the undersigned hereby gives a continuing individual and personal guarantee and promise to pay creditor all sums due on demand. • In the event Pitco Foods must refer this agreement to an attorney or any such outside agency for collections, any and ALL fees accrued will be responsibility of applicant. The undersigned hereby consent(s) to (name of creditor)'s use of a non-business consumer credit report on the undersigned in order to further evaluate the creditworthiness of the undersigned as principal(s) proprietor(s) an/or guarantor(s) in connection with the extension of business credit as contemplated by this credit application. The undersigned hereby authorize(s) Pitco Foods to utilize a consumer credit report on the undersigned from time to time as needed in connection with the extension or continuation of the business credit represented by this credit application. The undersigned as (an) individual(s) hereby knowingly consent(s) to the use of such credit report consistent with the Federal Credit Reporting Act.

e-signature of Applicant*

Date

MonthDayYear

e-Signature of partner

(Only if for a joint membership)

Date

MonthDayYear

*By clicking "Submit" you consent and agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action constitutes your signature, acceptance and agreement as if actually signed by you in writing. You understand and agree that your e-Signature executed in conjunction with the electronic submission of your application shall be legally binding and such transaction shall be considered authorized by you.

FOR OFFICE USE ONLY

VOD:_______________ Open Date:_______________ Rating:_______________ Re-eval:_______________

Credit:_______________ Terms:_______________ Matrix:_______________ Sales Rep:_______________ Sales Sup:_______________ Acct#:_______________

Authorization Agreement for Direct Payments