Wholesale Application

Contact Name *

First Name

Last Name

Store Physical Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Billing Address (if different)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Account Setup *

Pay by check upon delivery

Net 15 on all orders by credit card or check

Keep secured payment on file - charged upon delivery/pick-up

***ELECTRONIC SIGNATURE*** *

By entering your name and submitting this form, you agree that you are authorized to do so by the company and allow West Virginia Fruit and Berry to use this information as a basis for creating your wholesale account.

First Name

Last Name

Date

MM

DD

YYYY