NEW CUSTOMER INFORMATION
Company Name:
Phone:
Billing Address: (Include City, State & Zip code)
Shipping Address: (Include City, State & Zip code)
Type of Business (Installer / Re-wholesaler / Retailer / Architect / Municipality / etc.):
Products for Order (Sod / Plugs):
Variety:
When Needed:
Requested Quantity:
1-5 Pallets
6-16 Pallets
16 or more
Order Frequency (check which applies):
Weekly
Bi-Weekly
Monthly
Pickup or Delivery:
Delivery
Pickup
Forklift Needed?
Yes
No
Semi Needed?
Yes
No
Accounts Payable Contact:
Email:
example@example.com
Phone:
Please list those authorized to place orders for your company
Contact Name:
Email:
example@example.com
Phone:
Contact Name:
Email:
example@example.com
Phone:
Contact Name:
Email:
example@example.com
Phone:
Tax Exempt?
Yes
No
Tax Exempt Form
Browse Files
Cancel
of
State or Local Business License
Browse Files
Cancel
of
How did you hear about us?
*
Which Bethel Representative helped you?
*
CREDIT APP TO FOLLOW IF APPLICABLE
www.bethelfarms.com
(863) 494-3057
Preview PDF
Review and Submit
Should be Empty: