Customer Number Application

To apply for a customer number, please complete the form below.

This form is not an application for terms or credit. Credit applications are available under Resources/Forms.

* = Required Field
* Legal Business or Organization Name
* Bill to Address Line 1
Ship to Address Line 1 (if different from bill to address)  [?]
Bill to Address Line 2
Ship to Address Line 2
* City
* State
* Zip
City
State
Zip
Email Address:
* Phone Number:
Fax Number:
Employer Idenfiication Number / SSN
Owner's Name
Additional information may be requested to set up your account. For more information, contact our Sales Department.
* Are you a current customer of Midwest Groundcovers?
No    
Yes
* Are you Tax Exempt?
No    
Yes
* Do you require a Purchase Order Number or Job Name on your orders?
(Selecting a PO# and/or Job Name will not allow us to release an ordered without the required information.)
PO Required
Job Name Required
Both
Neither
* Primary First Name
* Primary Last Name
* Position
* Direct Phone Number
* Email Address
Add'l First Name
Add'l Last Name
Position
Direct Phone Number
Email Address
* What is your primary business?
Architect
Builder/Construction
Garden Center
Golf Course
Greenhouse
Landscaping
Nursery
State/Local Org.
Property Manager
Re-Wholesaler
Other