Wholesale Account Application - Shipley Farms Beef

1
Restaurant/Business Name, the "Company"* This field is required.
Legal name of the business
2
DBA or other trade name
Legal name of the business
3
Order Contact Person* This field is required.
First Name
Last Name
Phone number
Email address
Business Address
City, State, ZIP
4
Is the Order Contact Person same as Billing Contact Person?
YESNO
5
Billing Contact Person* This field is required.
First Name
Last Name
Phone number
Email address
Mailing Address
City, State, ZIP
6
Type of Entity* This field is required.
Corporation
Limited Liability Company
Partnership
Sole Proprietorship
Other
7
Business Information* This field is required.
Sales Tax Resale Certificate # (and state, if not NC)
Federal Tax I.D. Number
DUNS #
Business Start Date
8
Sales Tax Resale Certificate* This field is required.Please upload your sales tax resale exemption certificate here
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
9
W-9 Form* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
10
Trade References* This field is required.Please list 3 or more
11
Payment Preference* This field is required.
Pay on delivery, no credit terms needed.
I want to apply for credit terms.
12
Ownership* This field is required.List all owners with 20% or more ownership
13
Bank Reference
Bank Name
Account Number
Contact Person
Phone Number
Street, City, State, ZIP
14
Landlord* This field is required.
Name/Company
Please enter landlord's phone
Contact Person
Lease or Rent Amount per month
Street, City, State, ZIP
15
Acknowledgement:* This field is required.
I understand and agree that interest of 1.5% per month shall be imposed on overdue bills, in addition to any applicable collection charges. I authorize Shipley Farms Foods or its agent to investigate the company's credit and authorize any bank, mortgage lender or landlord, credit reference or any other party to release information to Shipley Farms Foods and hold harmless for said disclosure. The undersigned agrees to pay reasonable attorney’s fees and cost of collection and interest at the maximum legal rate in the event of any default under this obligation.
I certify that the information provided in this form is complete, true and correct.
16
By completing this form, I agree for this electronic submission to act as my legal signature.* This field is required.
Clear
17
Authorized Signature* This field is required.
Person Completing Application
Title/Position
18
Personal Guarantee

The within guarantee is made for the benefit of, and to obtain credit on a continuing basis from Shipley Farms Beef. The undersigned hereby guarantees the performance of all present and future obligations of     Company Name *     . The undersigned consents to any extension of any obligation. This guarantee shall continue in effect until the undersigned has notified Shipley Farms Beef in writing via certified mail of its cancellation, but such cancellation shall not alter any obligation of the undersigned arising thereunder prior to receipt of such written notice.

First Name *     Last Name *
SSN *
Application Date *
19
Credit Terms Requested* This field is required.
Electronic Payment - Day of Delivery
Net 7 Days
Net 14 Days
20
Credit Limit Requested
21
Payment Options* This field is required.
I would like to pay by credit card and will absorb a 3% processing fee.
Please keep my credit card on file
Should be Empty: