SHIP TO ADDRESS Business Name ________________________________________________ Street Address ________________________________________________ City ___________________________ST_____________Zip_____________ Phone_ _____________________ Contact___________________________ LOCATION OWNED —Name of Mortgage Holder ____________________________________________________________ Rented—Landlord Name ________________________________________ Landlord Phone________________________________________________ Do you require a PO# on all orders and invoices? Yes No Do you want us to email you a monthly statement of account? Yes No Email Address_______________________________ Is there other information needed on your invoice(s) to help you process your invoice for payment? If so, or a unique invoice email address, please provide: Are you a Group Purchasing Organization (GPO) member? If so, name of group: ____________________________________________________________ BANK REFERENCES Name of Bank ___________________________________________________ Phone _________________________________________________________ Address________________________________________________________ City ______________________________ST___________Zip______________ Checking #______________________________________________________ Loan#_ ________________________________________________________ Name of Bank Officer Name of Bank ___________________________________________________ Phone _________________________________________________________ Address________________________________________________________ City ______________________________ ST___________Zip______________ Checking #______________________________________________________ Loan#_ ________________________________________________________ Name of Bank Officer TRADE REFERENCES (Please provide Foodservice Industry suppliers if applicable) ______________________________________________________________________ (1) Supplier Name Acct# Phone ______________________________________________________________________ (2) Supplier Name Acct# Phone Your DON Sales Representative ____________________________________ Sales # _____________________________________________________
BILL TO ADDRESS
Legal Name of Firm (“Applicant”) ________________________________________ Trade Style (DBA) __________________________________________ Mailing Address ___________________________________________ City _____________________________ ST__________Zip__________ Phone_ ________________________________ Fax_ ______________ Cell Phone# _ _____________________________________________ A/ P Contact Person _ ______________________________________ E-mail Address_ ___________________________________________ Business Ownership: Proprietorship Partnership Corporation LP or LLP LLC State & Date of Legal Form _ _________________________________ How Long In Business Under Current Ownership? Years__________________ Months____________________________ Federal Tax ID #____________________________________________ NAMES OF OWNERS, PARTNERS, OR OFFICERS Name_______________________________________________________ Title_ _______________________________________________________ Home Address________________________________________________ City_ ______________________________ ST_______ Zip_ ____________ Home Phone_________________________________________________ Name_______________________________________________________ Title_ _______________________________________________________ Home Address________________________________________________ City_ ______________________________ ST_______ Zip_ ____________ Home Phone_________________________________________________ Name_______________________________________________________ Title_ _______________________________________________________ Home Address________________________________________________ City_ ______________________________ ST_______ Zip_ ____________ Home Phone_________________________________________________ Please list any related companies in which the above individuals are owners/partners/officers. If none, check here Business Name_______________________________________________ City_ _______________________________ ST_ _______________ Does above do business with DON? _ Yes No List any additional Business_ _________________________________ ________________________________________________________
Estimated monthly purchase from DON? _________________________
If monthly purchases will exceed $25,000 please attach your most recent financial statement.
WWW.DON.COM — CUSTOMER SIGN-UP
Would you like free access to DON.com - DON’s proprietary web site, which will allow you to place orders, search items, view images, and verify your payables? If so, please fill out the following information for the person that would be the main user of the web site and receive all marketing publications. Mail To Name____________________________________________ E-mail Address__________________________________________________ Mail To Address _________________________________________ City_ ________________________ST__________ Zip_ __________ Contact Phone___________________________________________________ (By listing your email address, you have opted-in to receive e-mail from DON regarding future offers and communications.)
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