House Account Request Form

House Account Request Form
Company Name*
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company DUNS #*
If you don't know your DUNS #, please visit and find yours!
Company EIN*
Found on company's W-9 form.
Please upload your W-9*

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House Account Questionnaire
What is the closest Mendocino Farms location to your office?*
To find a location near you, please click Here!
How often does your office get catering? (from any restaurant)*
As a company, what specific needs do you have that requires a house account? *
How many employees are in your office?*
Can you leave a credit card on file for future orders?*

YesNo
We have a minimum of $12,000 annual spend for house accounts. Are you able to meet this requirement?*

YesNo
If no, please provide an estimate annual spend.
Do you agree to Net 30 terms?*

YesNo
House Accounts are for catering orders only. Does this align with your needs?*

YesNo
Are you able to pay via ACH?*

YesNo
Approved Users
Approved User 1*

First NameLast Name
Approved User 1 Phone Number*
Please enter a valid phone number.
Approved User 1 Email*
example@example.com
Approved User 2

First NameLast Name
Approved User 2 Phone Number
Please enter a valid phone number.
Approved User 2 Email
example@example.com
Approved User 3

First NameLast Name
Approved User 3 Phone Number
Please enter a valid phone number.
Approved User 3 Email
example@example.com
Approved User 4

First NameLast Name
Approved User 4 Phone Number
Please enter a valid phone number.
Approved User 4 Email
example@example.com
Approved User 5

First NameLast Name
Approved User 5 Phone Number
Please enter a valid phone number.
Approved User 5 Email
example@example.com
Accounts Payable Information

Billing, statements and payments
Accounts Payable Contact Name*

First NameLast Name
Accounts Payable Contact Email*
Accounts Payable Phone Number*
Please enter a valid phone number.
Invoicing Email Address*
Applicant Contact Information
Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid number.
DUNS Credit Report

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Terms and Conditions
Have you read our Terms and Conditions?

Yes
Signature

Clear
Thank you for your interest in establishing a house account with Mendocino Farms. We are unable to approve you at this time due to 1 or more of the conditions not being met. If you think this is an error, please reach out to michelle@mendocinofarms.com
Should be Empty:

House Account Request Form

House Account Questionnaire

Approved Users

Accounts Payable Information

Applicant Contact Information

Terms and Conditions