New Customer Information Form

To ensure that you are set up in our system properly, we must receive this form prior to your first order.

Company/Business Information

Company Name *

How long have you been in business? *

Email *

Cover Letter *

Mailing Address *

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Delivery Address

Leave blank if Delivery Address is the same as Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Days & Hours of Operation *

Receiving Hours *

Company Contact Information

Owner/Principal Name: *

Owner/Principal Name:

First Name

Last Name

Owner/Principal Phone: *

Owner/Principal Phone:

(###)

###

####

Owner/Principal Email: *

Payment Contact Name: *

Payment Contact Name:

First Name

Last Name

Payment Contact Phone: *

Payment Contact Phone:

(###)

###

####

Payment Contact Email *

Ordering Contact Information

Ordering Contact Name *

Ordering Contact Name

The person in charge of placing orders.

First Name

Last Name

Ordering Contact Phone: *

Ordering Contact Phone:

(###)

###

####

Ordering Contact Email: *

Order Reminder Preference *

To help remind you to place an order, select an option for the best method of contact for a reminder.
If you choose "Text Message", please enter a cell phone number in the "Ordering Contact Phone" section.

Phone Call

Text Message

None

Confirmation of Information Accuracy

I/we certify that all of the information given above is correct and that I/we fully understand The Bread Shed's Terms & Conditions of Sales and agree to the proper payment. (See below)

Terms and conditions: Payment is due within 30 days of invoice, or balance of $800, whichever comes first. We reserve the right to discontinue service until payment is made if account is not current.