Casey’s Distributing Account Application 08-04-2017
CASEY’S ACCOUNT APPLICATION
Casey’s Distributing, Inc. - Omaha, Nebraska 8921 J Street, Suite 300 Omaha, NE 68127 Phone: (402) 334-3485 | Casey’s Distributing, Inc. - Columbus, Ohio 2735 Westbelt Drive Columbus, OH 43228 Phone: (614) 527-1200 |
Email a signed copy to membership@caseys-distributing.com or fax a signed copy to (402) 625-0501
BUSINESS INFORMATION:
TYPE OF BUSINESS: ____ SOLE PROPRIETOR _____ PARTNERSHIP _____CORPORATION
TAX ID #: ___________________ DATE STARTED: _____________ ANNUAL SALES: _____________
LEGAL NAME/DBA: __________________________________ MAIN PHONE: ____________________
BILLING ADDRESS: ___________________________________________________________________
CITY: ______________________________ STATE: ______ ZIP: __________________
WEBSITE ADDRESS: _____________________________________________________________
PRESIDENT, OWNER, OR PARTNER NAME: _______________________________
PRESIDENT, OWNER, OR PARTNER E-MAIL ADDRESS: ____________________________________
OTHER AUTHORIZED PARTY NAME:_______________________________
OTHER AUTHORIZED PARTY E-MAIL ADDRESS: _________________________________________
PERSON PAYING BILLS: ______________________________ TELEPHONE: ____________________
PERSON PAYING BILLS E-MAIL ADDRESS: _________________________________________
NOTE : ATTACH A COMPLETED SALES TAX RESALE CERTIFICATE(S)
THE UNDERSIGNED HAS READ THIS APPLICATION AND AGREES TO BE BOUND BY ITS STATEMENTS AND CASEY’S TERMS AND CONDITIONS. THE UNDERSIGNED AGREES TO UPDATE THIS APPLICATION IF INFORMATION IS NO LONGER ACCURATE.
NAME_______________________________________________ TITLE____________________
SIGNATURE__________________________________________ DATE____________________
Page of Casey’s Distributing, Inc. 8921 J Street, Suite 300 Omaha, NE 68127 (402) 334-3485