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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