Customer Form – Lakeside Nursery

Company Name *

First Name of Applicant *

Last Name of Applicant *

Title *

Phone Number *

Are you the owner? *

Will you be the main purchaser on the account? *

Names of authorized purchasers, if applicable:

Type of business: *

License #:

Type of License:

Please describe the primary nature of your business: *

Which products are you interested in purchasing? *

PO numbers or job names required on purchases?

Company Owner First Name *

Company Owner Last Name *

Billing Address, City, Zip Code *

Office Phone *

Fax:

Email Address (For invoices and statements) *

Email Address (For orders and quotes) *

Do you want purchases taxed? *

Resale License #: