EmailMe Form - Wholesale Account Information

COMPANY INFORMATION

Company Name *

Billing Address *

City, State, Zip *

Telephone No. *

Fax No.

Type of Business *

State Incorporated *

Business Type
(check one) *

Principal/ Owner *

Principal/ Owner
E-mail Address *

Authorized Buyer *

Authorized Buyer
E-mail Address *

Chef/ Manager *

Chef/ Manager
E-mail Address *

Website *

Business Hours *

E-mail Address

Certifications if any

Certified Organic

Certified Humane

Other

Receiving Hours if Different

PERSONAL GUARANTEE

I understand I will be required to provide payment and banking information
as well as documentation for sales tax exemption and other wholesale
privileges to establish an account with Ayrshire Farm LC.

Printed Name *

Date Signed *

Please check one *

I agree

I do not agree