Online Application – Upper Valley Produce

***Please Fill Out Completely***

For accounts with more than one shipping location, please fill a separate form for each location.

Main Account Information
Legal Business Name
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
DBA:
Federal Tax ID#
Requested Term*
If no trade references are provided, then terms will be COD by default. Please attach references to application.
Business Type*
Owner Name
First Last
Owner Phone
Billing/Accounting Contact Information
Billing/Accounting Contact Name
First Last
Phone
Email
Additional Billing/Accounting Contact Name
First Last
Phone
Email
Ordering Contact Information
Primary Contact Name
Name Position
Phone
Email
Authorized for online ordering?
Would you like Pricing and Specials emailed to you?
Additional Contact Name
Name Position
Phone
Email
Would you like Pricing and Specials emailed to you?
Would you like Pricing and Specials emailed to you?
Delivery Information
Ship to Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Hours of Operation
Ok to drop?
Do we need a key or door code? If Yes, please specify:
Where is the delivery entrance? Be specific
Earliest Delivery Time:
Latest Delivery Time:
Are there any days you will NOT accept deliveries?
Special Instruction or Delivery Preferences?
Contact name if no one is around and drops are not authorized:
Contact phone if no one is around and drops are not authorized:

Main Account Information