Wholesale Application

Applicant Information
Company Name:
Primary Contact:
Physical Address 1:
Mailing Address 2:
City:
Zip Code: (5 digits)
State:
Owners Information
Name:
Name:
Drivers License #
 
 SS# or FIN#
 
 Physical Address
 
 Res. Phone
 
 Bus. Phone
 
 Cell Phone
 
Contact Information
Daytime Phone:
Evening Phone:
 Fax Phone:
 
Website:  
Email:
Business Information
License Type:  
 County/State
 
Financial Information
Bank Name:
Account Number:
Phone Number:

Reference w/ Contact Name, Address, Phone and Fax:
Reference 1:
 Reference 2
 
I authorize CITY NURSERY FARM to verify
my credit and account history.

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