Wholesale Customer Application
I am applying for membership in Frontier Natural Products Co-op. I
understand that I have 30 days to pay the $10 membership fee.

I wish to buy as a non-member. I understand I will be charged a non-refundable 5% surcharge on my purchases.

Name of your organization

Do you wish to be considered for credit terms? Yes No

Signature
I acknowledge that by typing my name above, I am indicating my intent to sign the document and that this shall constitute my signature.
Billing Address
Name
Street Address
City
State Zip
Delivery location: Commercial Residential
Shipping Address (if different)
Name
Street Address
City
State Zip
Delivery location: Commercial Residential
Note: Package delivery services need a deliverable street address. Post office boxes are not acceptable.
Phone Number
Phone # Fax #
E-mail/Web Address
E-mail
Web Site
Do you currently sell online? Yes No
Contacts
  1. Name
    Phone

  2. Name
    Phone
List your state resale tax ID number, if applicable


Please check the category that best applies to your organization with regard to Frontier products
Natural Foods Retailer
Grocery
Buying Club
Industrial
Internet Only Store
Other Wholesale

We are required by the IRS to get a Taxpayer Identification Number from you. Please fill in your Employer Identification Number (EIN) or Social Security Number (SSN) below and sign the officially worded IRS certification.
Name EIN or SSN

Under penalties of perjury, I certify that:
1. The number shown is my correct taxpayer identification number (or I am waiting for a number to be issued to me),

and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding.

Signature
I acknowledge that by typing my name above, I am indicating my intent to sign the document and that this shall constitute my signature.