New Customer Application – Brehob Nurseries

Full Business Name: *

Address (street, city, state, zipcode): *

Street Address, City, State, Zip Code

Phone Number: *

Office Phone Number

Cell Phone Number: *

Email: *

Years in Business: *

Federal ID Number: *

Nursery Dealers License: *

Requirement for any person who grows or buys nursery stock for the purpose of reselling or reshipping that stock in Indiana. This can be found on the Indiana DNR's website at https://www.in.gov/dnr

Indiana Retail Merchants Certificate:

Required for Retailers or Re-wholesalers (can be found on State of Indiana's website)

PO or Job Name Required? *

Yes
No

Tax Exempt? *

Yes
No

If yes, an ST-105 form MUST be on file before you will be considered tax exempt. The form can be mailed or emailed to the Distribution Center

Type of Business: *

If Other please explain:

Types of Services Offered: (choose all that apply) *

Authorized Buyer (only people on your approved list will be allowed to purchase): *

Name, Position, Cell phone

Authorized Buyer:

Name, Position, Cell Phone

Authorized Buyer:

Name, Position, Cell Phone

Trade References: (names of business or individuals who can substantiate your business) *

(Name, Phone Number, Address) *No Credit information will be asked

Trade References: *

(Name, Phone Number, Address) *No Credit information will be asked

Trade References: *

(Name, Phone Number, Address) *No Credit information will be asked