Wholesale Customer Application

Wholesale Customer Application

Apply to become a wholesale customer of Diemand Farm. **You must be approved as a new wholesale customer before you can place an order.
Business Name *
Business Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Physical Address (if different than mailing address)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
General Business Phone Number *

Area Code Phone Number
Contact Name *

First Name Last Name
Contact Email *
example@example.com
Contact Phone Number (if different from General Business Phone Number)

Area Code Phone Number
Preferred Method of Contact *
Days and Hours of Operation *
Include hours available to accept deliveries if different from regular store hours.
Which products would you like to purchase? Choose all that apply. *

Wholesale Soups Wholesale Pot Pies Wholesale Eggs (if available) Wholesale Chicken (if available) Wholesale Turkey (if available)
Include any special requests or notes below:
If you are accepted as a wholesale customer and are within our delivery area, there will be a $2.00 fee added to all deliveries. Note that deliveries are limited during the month of November.
Retail/Wholesale

Wholesale
Application *

Application
Should be Empty: