Professional Services Contract Farm

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6625 Caballero Road
Buena Park, CA 90620-1158
(714) 736-1800 (714) 736-1801
F A R M S
F A R M S
BUSINESS INFORMATION
NAME: _____________________________________________ EST. SINCE: _______________
NAME OF PARENT CO: _______________________________
BUYING NAME/DBA: __________________________________ TEL: ____________________ FAX: _________________
MAILI ____________________ FAX: _________________
CITY: _______________________________________________ STATE: ______ ZIP: __________
TYPE OF BUSINESS (CHECK ONE)
___ BROKER
___ WHOLESALE
___ CORPORATION
___ RETAIL
___ FOOD SERVICE
___ PARTNERSHIP
___ OTHER
___ PROPREITORSHIP
___ GENERAL OR LIMITED
LIST OWNERS, PARTNERS OR CORPORATE OFFICERS
NAME: _______________________________________
TEL: ____________________ SS# ________________________
HOME ADDRESS: ____________________________________ CITY: __________________ STATE: _____ ZIP: ________
NAME: _______________________________________
TEL: ____________________ SS# ________________________
HOME ADDRESS: ____________________________________ CITY: __________________ STATE: _____ ZIP: ________
OWN BUSINESS PROPERTY:
____ YES
____ NO
IF YES
VALUE $ ____________________________
IF NO
RENT $ ____________________________
LANDLORD NAME: ____________________________ ADDRESS: _____________________________________________
PURCHASING
ARE PURCHASE ORDERS REQUIRED TO CHARGE YOUR ACCOUNT:
____ YES ____ NO
LICENSED WITH PACA NO: ___________________________________
DEPT OF FOOD & AGRICULTURE BUREAU OF MARKET ENFORCEMENT NO: __________________________________
FEDERAL TAX ID: ___________________________________
TRADE REFERENCES
NAME: _______________________________________
TEL: ____________________ FAX: ______________________
ADDRESS: ____________________________________ CITY: ____________________ STATE: _____ ZIP: __________
CONTACT: ____________________________________
NAME: _______________________________________
TEL: ____________________ FAX: ______________________
ADDRESS: ____________________________________ CITY: ____________________ STATE: _____ ZIP: __________
CONTACT: ____________________________________
NAME: _______________________________________
TEL: ____________________ FAX: ______________________
ADDRESS: ____________________________________ CITY: ____________________ STATE: _____ ZIP: __________
CONTACT: ____________________________________
NAME: _______________________________________
TEL: ____________________ FAX: ______________________
ADDRESS: ____________________________________ CITY: ____________________ STATE: _____ ZIP: __________
CONTACT: ____________________________________

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