New Reseller Customer Form

New Reseller Customer Questionnaire

Company Name *

Mailing Address *

Office Phone Number *

Primary Billing Contact Name *

Primary Billing Contact Phone Number *

Primary Billing Contact Email *

Shipping Address 1 *

Is there a loading dock available at this shipping address? *

yes

Do you have multiple shipping addresses? *

If Yes, please list the multiple shipping addresses in this text box below and note if they have a loading dock available.

Name of your sales representative. *

Are you sales tax exempt? *

If yes, please provide a copy of your sales tax exemption form before you complete this questionnaire to [email protected] in order to avoid being charged sales tax.

Does your company have a pesticide dealer, applicator, or other chemical license from your state? *

If yes, please upload a copy of your license or email a copy of your license to [email protected]

Click on the arrow and upload the copy of your license.

Do you want to apply for credit terms? (if no, you will be required to pay upfront before receiving delivery) *

If yes, provide the dollar amount of credit limit for which you would like to apply

If yes, please provide your company’s DUNS #

If your company does not have a DUNS #, please click the blue hyperlink below and follow the instructions to procure a free DUNS # and then complete the fillable line above.

For DUNS # Directions Click Me...

By submitting this form and signing up for texts, you consent to receive conversational text messages (e.g., intake reminders) from I&B Ag Supply at the number provided. Consent is not a condition of purchase. Msg & data rates may apply. Msg frequency varies. Unsubscribe at any time by replying STOP. Reply HELP for help. *

I agree to receive marketing texts e.g shopping offers at the number provides

I agree to receive non-marketing texts e.g appointment reminders updates at the number provided

I confirm all the information above is accurate. *

yes

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