EFC New Account Application - Eastland Food Corporation

8305 Stayton Drive, Jessup, MD 20794
606 Territorial Drive Suite A, Bolingbrook, IL 60440
9735 Patriot Blvd, Suite B, Ladson, SC 29456

Tel: (410) 381-0710 Fax: (410) 381-2079
Tel: (630) 633-2470 Fax: (630) 633-2479
Tel: (843) 371-5827 Fax: (843) 371-5827

New Customer Application

BUSINESS GENERAL INFORMATION - Step 1 of 9

Business Name *

Business Address *

Address Line 1

Address Line 2

City

State

Zip Code

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Business E-mail *

Business Phone

Business Type *

Retail Market
Convenience Chain
E-Commerce
Retail Chain (Multiple Location)
Manufacturer
Food Service
Wholesales & Distributor
Restaurant

Retail Market Type *

Asian Market
Hispanic Market
Mainstream Market
Others

Wholesales & Distributor Type *

Asian Market
Hispanic Market
Mainstream Market
Others

Retail Chain Type *

Asian Market
Hispanic Market
Mainstream Market
Others

Restaurant Type *

Asian Market
Hispanic Market

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Prefix *

Name *

First

Last

Home Address *

Address Line 1

City

State

Zip Code

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Home Phone

Cell Phone *

Other Language Prefered

Other Prefered Languages

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Identification *

Social Security Number *

Driver License Number *

Passport Number *

Type of Ownership *

Sole Proprietorships
Partnerships
C Corporations
Corporations
Limited Liability Company (LLC)

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Date Current Ownership Established

Federal Taxpayer ID *

Business License Number *

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DUN#

Experian BIN#

First Trade Reference Info

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Company Name *

Company Address *

Email *

Phone Number *

Fax Number

Second Trade Reference Info

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Company Name

Company Address

Phone Number

Fax Number

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Bank Reference (Required)

Bank Name

Bank Address

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Account Number

Account Type

Checking
Saving

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Contact Name

Phone / FAX

Additional Bank Reference (Optional)

Bank Name

Bank Address

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Account Number

Account Type

Checking
Saving

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Contact Name

Phone / FAX

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Personal Guarantee Info

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Personal Name

Name

Personal Address

Address

Personal Phone

Phone

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Terms and Conditions

I/We hereby affirm that the above information is true and authorize Eastland Food Corporation to verify the information provided.

I/We authorize my/our trade references to release credit and financial information to Eastland Food Corporation. Upon approval of credit, I/We agree to pay in full and in accordance with the terms of payment indicated on Eastland Food Corporation invoices.

By signing you agree to the above statements *

Clear Signature

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Supported information for delivery/ truck driver

Business Trade Name / Business Sign *

Business Operating Hours

Business Days *

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Business Hours

Open *

Close *

Delivery Hours

Use Business Hour

Same with Business Hours

Delivery Days *

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Delivery Hours

Open *

Close *

Business Shipping Address and Contact Information

Shipping Address *

Address Line 1

City

State

Zip Code

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First Delivery Contact Person *

Second Delivery Contact Person

First Delivery Contact Phone *

Second Delivery Contact Phone

Shipping Accessibility

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Dock Load Available *

Accessible Vehicle Type *

Small Truck
Tractor Trailer
Both

Unload Location *

Front
Back

Additional Note for Driver (if any)

Customer must provide safe and adequate unloading facilities for Eastland Food Corporation delivery equipment *

Agree

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This is to certify that all tangible personal property or taxable services purchased from EASTLAND FOOD CORPORATION are intended for resale as tangible personal property or for use or incorporate as material or part of other personal tangible property to be produced for sale.

This certificate shall be considered as a part of each order we shall give, provided that the order bears our State Sales and Use Tax Registration License Number, and is to continue in force until revoked.

Sales and Use Tax Registration License Number *

Signature *

Clear Signature

Print Name *

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Business License *

Click or drag a file to this area to upload.

Please upload a copy of your business license (.pdf, .jpg, .jpeg, .png) maximum 5MB

Sales and Use Tax Registration License (Optional)

Click or drag a file to this area to upload.

Please upload a copy of your Sales and Use Tax Registration license (.pdf, .jpg, .jpeg, .png) maximum 5MB

Eastland Food Representative Name:

Order Online

I would like to have Order Online Account

Online Account Email *

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry.

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Email *