Application for Cash Account

Application for Cash Account

Step 1: Resell/Exemption Cerfification.

In order for us to comply with the State of Kansas Sales and Use Tax Laws, we are required to have a signed Resell/Used Certification on file.

Step 2: Submission of Application

By submitting the application you certify that you have the authority to submit this information and request an account for this company.

Billing Address for Bankcard.

Please enter your Name. Company Name *

PO Box

Please enter your Street Address. Street Name *

Please enter City City *

State

Five Digit Zip Code and Four Digit Postal Code *

Pleae enter Telephone number Phone Number *

Is this also your Shipping Address?
Yes No

If no, fill in shipping address.

Company Name.

Owner's Name *

PO Box.

Street Name.

City.

State.

5 digit Zip Code dash (-) 4 Digit Postal Code.

Phone Number.

Fax Number

Please enter a contact e-mail address. E-mail Address

URL

Do you use P.O. numbers?
Yes No

Do you have a CFC certification?
Yes No

If yes please fill out our EPA/CFC Certificate under the New Customer Forms tab.

Do you have an account with us? Or have you had an account with us in the past?
Yes No

If so when?

Under what name?

Do you want your Bank Card information kept on file?
Yes No

Are you Tax Exempt?
Yes No

If you answered Yes to Tax Exempt, please fill out the Tax Form under the New Customer Tab on the Main Website

Would you like to be set up with Online Shopper?
Yes No Already have One

If you answered Yes to Online Shopper, please fill out an ID/Password no more than 8 Characters long.

Online Shopper Login

Online Shopper Password

Please List People Authorized to Use this Account

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