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
* Legal Business or Organization Name
* Bill to Address Line 1
Ship to Address Line 1 (if different from bill to address)  [?]
Bill to Address Line 2
Ship to Address Line 2
* City
* State
* Zip
City
State
Zip
Website URL:
* Phone Number:
Fax Number:
Employer Idenfiication Number (EIN)
Note: If you do not have a Federal Employer Identification Number (EIN), please provide 2 proofs of business, such as:
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 Sales Department.
Owner's Name
Upload/Attach Documents Here
* Are you Tax Exempt? (If you will not be paying tax, please complete a Tax Exempt Form.)
No    
Yes
* Do you require a Purchase Order Number or Job Name on your orders?
(Selecting a PO# and/or Job Name will not allow us to release an ordered without the required information.)
PO Required
Job Name Required
Both
Neither
* Primary First Name
* Primary Last Name
* Position
* Direct Phone Number
* Email Address
Add'l First Name
Add'l Last Name
Position
Direct Phone Number
Email Address
* How will you be receiving your plants most frequently?
I will pickup
Midwest will deliver
* What is your primary business?
Landscape Contractor
Landscape Architect
Landscape Designer
Nursery Re-Wholesale
Nursery
Garden Center
Builder/Contractor
Multi-Nursery/Garden Center/Landscape Contractor
Government/Municipality/Park District
Other
* Would you like to be part of our Custom Color Label Program? 
Yes - One customized color label on each pot. By special agreement. Added charges apply. More information available upon request
No
Please list all green industry professional association memberships, accrediations, and certifications:
* How Did You Hear About Us?
Advertisement
Trade Show
Website
Referral
Other
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