Belair Produce New Customer Application

Please fill out and submit all three forms to have your application reviewed as a new customer. If you have any questions please call the office at (410) 782-8000 | Terms & Conditions

Customer Application

Sales Person

Date

MM

DD

YYYY

Trade Name

Full Legal Name of Business

Street Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Business Telephone

(###)

###

####

Fax

(###)

###

####

Owner's Email

Owner's Cell Phone

(###)

###

####

Checkbox

Independent Proprietorship

Corporation

Partnership

LLC

Date Business Opened

MM

DD

YYYY

Federal Tax ID#

Is Billing Address the Same as Shipping Address

Yes

No

If No, What is the Billing Address?

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Hours of Operation

Preferred Delivery Times

Delivery Location & Special Instructions

Purchasing Agent or Manager's Name

First Name

Last Name

Email Address

Cell Phone Number

(###)

###

####

Accounts Payable Contact Name

First Name

Last Name

Contact Phone

(###)

###

####

Fax Number

(###)

###

####

Email Address

Credit Terms Requested:

C.O.D

Credit Terms

7,14,21 or 30 days

Pay By Credit Card

Yes

No

Bank Name

Account Number

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Account Manager

First Name

Last Name

Phone Number

(###)

###

####

Trade References

No liquor companies, restaurant related only. Please provide the name, phone number, facsimile and account number of three references.

Belair Policy Statement Signature

The undersigned attest that they are an Owner, Partner, or Officer or Authorized Agent and hereby request Belair Produce, on behalf of applicant to establish a business account and extend credit to Applicant, subject to the terms and conditions established by Belair Produce and by PACA Trust Provision (Perishable Agricultural Commodities Acts) which are set forth on the attached hereto. Applicant agrees to be bound by said terms and conditions.

First Name

Last Name

Title

Date

MM

DD

YYYY

Letter of Authorization

Name

I hereby authorize Belair Produce, Inc to charge to following credit card

First Name

Last Name

Account Name

Phone Number

(###)

###

####

Email

Type of Card

Visa

Mastercard

Credit Card Holder

Credit Card Number

Authorization Code

3 digits on the back of the credit card.

Expiration Date

MM

DD

YYYY

Name of Bank

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Disclosure

Amount of the balance of my account with Belair Produce Inc. every week will be charge. If for any reason my card is declined, I agree to pay 2.9% re-processing fee(s) to Belair Produce Inc., Purchases made by the above account are to be charged to the credit card listed.

First Name

Last Name

Date

MM

DD

YYYY

Cardholder's Signature

First Name

Last Name

Personal Guarantee

Business Name:

To induce Belair Produce Inc. to sell merchandise, extend credit, or continue doing either to the below named customer, the undersigned jointly and severally guarantee full payment for all products sold or to be sold to

Trading As:

Consent to any extension or indulgence granted to:

Waive prior recourse and notice of non-payment.Should any payment not be made when due, the undersigned authorize any attorney designated by Belair Produce, Inc. to appear in any court of competent jurisdiction and confess judgment against them for the amount due with costs of suit, Interest at twenty four percent (24%) per annum, and including, but not limited to, all attorney fees, waiving homestead and all other exemptions, stay of execution, and right of appeal. Should the authorization for confession of judgment be deemed invalid, the remaining provisions of this instrument shall remain in full force and effect.

Corporation

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name(s) of Authorized Signature(s)

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Signature

First Name

Last Name

Social Security Number

Name(s) of Authorized Signature(s)

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Signature

First Name

Last Name

Social Security Number

Belair Produce New Customer Application

Customer Application

Letter of Authorization

Personal Guarantee

Subscribe to our Newsletter