Wholesale Application — COCKEYE CREAMERY

Apply for wholesale account

Company Name

As shown on Federal Tax Return

Alternate Name

If applicable

Tax ID Number

FEIN or SSN

Point of Contact Name

First Name

Last Name

Title

Vendor Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Vendor Delivery Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Phone Number

(###)

###

####

Contact Email

Tax Exempt

Yes

No

Vendor Website

http://

Organization Type

Corporation

LLC

Sole Proprietor

Non Profit

Terms Requested

COD

ACH Transfer