Customer Number Application

To apply for a customer number, please complete the form below.

This form is not an application for terms or credit. Credit applications are available under Resources/Forms.

* = Required Field
Application Type (check one or both):
» Midwest Groundcovers Application?
 Yes
 No
» Midwest Trading Application?
 Yes
 No
Please check the appropriate box below.
 New Customer
 Customer Change
* Legal Business or Organization Name
* Website
* Bill To Address
* City
* State
* Zip
* Phone
Fax
How will you receive your orders most frequently?
Pick Up
Delivery
Ship To Address (if different than bill to)
City
State
Zip
Phone
Fax


Business Identification Information

Employer Identification Number
AND/OR Owner's SSN
* Owner's Name
NOTE: If you do not have a Federal Employer Identification Number (EIN), please provide 2 proofs of business such as a: voided business check, business license, state certificate of business registration, membership in a professional association, trade association or chamber of commerce. Additional information may be requested to set up your account. For more information, contact our Customer Service Department.

* Would you like to apply for credit terms?
Yes
No
* Would you like to put your credit card information on file?
Yes
No
By checking "Yes", a sales representative will contact you to receive your information. Credit applications are available separately.


Contact Information

*Main Contact Name
* Phone Number
* Email Address
Buyer 1 Name
Phone Number
Email Address
Buyer 2 Name
Phone Number
Email Address
Admin/Accts Payable Name
Phone Number
Email Address
Do you require a Purchase Order # or Job Name on your orders?
PO Number
Job Name
Please list any other special ordering details:


Primary Business

Contratisto Latino
Garden Center
Green Roof
Greenhouse Grower
Landscape Architects and Estimators/Specifiers
Landscape Contractor
Natural Garden Natives®
Nursery Grower
Public Entities: Municipality Park District Forest Preserve
Restoration Contractor
Rewholesaler
Other
* Are you tax exempt?
Yes
No