Customer Application - On-Line Form

This is not a credit application

Applications will not be approved without a valid Indiana Nursery Dealer's License. An Indiana General Sales Tax Exemption Certificate (Form ST-105) must be submitted to us separately, before sales tax can be waived.

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select the option to print the Customer Application form.

Company Name:
Street Address:
City, State & Zip:
Cell Phone:Pager:

Years in Business:

Nursery Dealers License:
Federal ID Number:

Indiana Retail Merchants Certificate Number:

Type of Business (Check All that Apply):


Authorized Buyers:
Name: Position: Cell Phone: 
(company's main contact person)
Name: Position:
Name: Position:

Trade References (business relationships): Please provide names of business
or individuals who can substantiate that your business
is a retail garden center or landscape company that
does installation of plant material, i.e. commercial
customers, other suppliers, equipment vendors, etc.
No credit information will be asked.

Name:  Phone: 

Name:  Phone: 

Name:  Phone: 

Note: If approved, payment is to be made at the time of purchase by cash, company Visa or MasterCard, or company check.  Firms wishing an open account status must apply on a separate credit application.   
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Brehob Nursery, Inc. Mother Nature's Finest, Indiana's Best Westfield Noblesville Indianapolis
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