New Customer Application

URL

This field is for validation purposes and should be left unchanged.

Account Name*

Parent/Affiliate Company*

Yes

Parent/Affiliate Phone*

Contact Name*

Parent/Affiliate Email*

Billing Address*

Street Address or PO Box City State ZIP Code

Delivery Address*

Street Address City State ZIP Code

Phone*

Fax

Email*

Website Address

Owner/Principal Officer*

First Last

Tax Identification*

Federal Tax ID (EIN)

Social Security

Federal Tax ID Number*

For security purposes we will contact you separately to obtain your Social Security number.

Company Designation*

Corporation

Partnership

Individual

Govt. Agency

Other (Specify)

Other*

Year of INC

State of INC

In Business Since

Type of Business*

Credit Requested ($)

D&B#

Purchase Orders Required?

Yes

Buyer Contact*

Buyer Email*

Buyer Phone*

AP Contact*

AP Email*

AP Phone*

C.O.D Customers - Check below to skip to signature.

C.O.D Customer

I authorize my bank listed below to release information to Spring Valley Dairy, Inc for credit purposes:

Principal Bank*

Bank Contact*

Phone*

For security purposes we will contact you separately to obtain your account number.

Bank Address*

Street Address City State ZIP Code

Trade/Credit References

Name*

Phone*

Email*

For security purposes we will contact you separately to obtain your account number.

Reference Address*

Street Address City State ZIP Code

Name

Phone

For security purposes we will contact you separately to obtain your account number.

Reference Address

Street Address City State ZIP Code

Name

Phone

For security purposes we will contact you separately to obtain your account number.

Reference Address

Street Address City State ZIP Code

This application is submitted for the purpose of obtaining credit with Spring Valley Dairy Inc. and is warranted to be true. By signing this application the undersigned acknowledges that he/she is authorized to execute this application and to obligate the company to make payment in full for all amounts due according to invoice on or before the net due date. Additionally, the undersigned will be responsible for all collection costs and attorney fees, with or without lawsuit, in order to collect any delinquent moneys. The undersigned hereby authorizes Spring Valley Dairy Inc., to make such inquiries (corporate/personal) as are necessary to obtain credit information and authorizes the bank(s) of record to release information regarding accounts.

Signature of Owner, Partner or Corporate Officer*

Date*

Printed Name of Signer*

Title*