Vendor Registration

Registration

Username*

Email*

First Name

Last Name

Store Name*

https://agriculturalbourse.com/store/[your_store]

Address 1*

Address 2

Country*

City/Town

State/County

Postcode/Zip*

Store Phone*

Sales Contact 1 Name

Sales Contact 1 Phone

Sales Contact 1 Email

Sales Contact 2 Name

Sales Contact 2 Phone

Sales Contact 2 Email

Invoicing Contact Name

Invoicing Contact Phone

Invoicing Contact Email

Bill of Lading Contact Name*

Bill of Lading Contact Phone*

Bill of Lading Contact Email*

Inventory Contact Name*

Inventory Contact Phone*

Inventory Contact Email*

Mailing address same as Principal Business Address

Location of Books and Financial Records same as Principal Business Address

No Other Offices or Locations

Alt Phone

Company Fax

Company Email

Website

Type of Legal Entity

Origination Date of Legal Entity

State Legal Entity Originated

County Legal Entity Originated

PACA License Number

Trade Styles or Other Names

Articles of Incorporation

Liability Insurance

Food Safety Certificate 1

Food Safety Certificate 2

PACA License

Organic Certificate

Signature*

Date*

Password*

Confirm Password*

* Agree  Terms & Conditions