Merchants Foodservice | Customer Application

Thank you for your interest in becoming a customer of Merchants Foodservice.
Before getting started, please provide your full name and a valid email address.
Full Name*
Email Address*
Sales Rep Name/Number
Please enter the Name and/or DSR number of your Merchants Sales Rep, if you know it.

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Add all of the owners of your company. Use the 'Add Another Owner' button to add more.
Owner #1
Full Name*
% Owned*
Home Phone No.*
Title (if Corp.)
Social Security No.
Rent or Buy?
- Rent
- Buy
Home Address*
Address City State ZIP Code
Date of Birth*
Drivers License No.*
Driver's License*
Accepted file types: jpg, tga, png, gif, pdf, tif.
Upload a copy of your Driver's License here
Add Another Owner?*
- YES
- NO
Owner #2
Full Name*
% Owned*
Home Phone No.*
Title (if Corp.)
Social Security No.
Rent or Buy?
- Rent
- Buy
Home Address*
Address City State ZIP Code
Date of Birth*
Drivers License No.*
Driver's License*
Accepted file types: jpg, tga, png, gif, pdf, tif.
Upload a copy of your Driver's License here

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Provide both accounts payable and banking information here.
Accounts Payable Contact*
Phone No.*
Anticipated Weekly Purchases*
Federal Tax ID*
State Tax ID*
Sales Tax Certificate*
Accepted file types: jpg, tga, png, gif, pdf, tif.
Upload a copy of your Sales Tax Certificate here
Name of Bank*
Bank Contact
Bank Address*
Address City State ZIP Code
Bank Account No.*
Bank Phone No.*
Terms Requested*
ACH Debit Authorization
The purpose of this form is to authorize electronic debit transactions.
I authorize the payment of (choose one):*
Payment Frequency
9 Digit Routing Transit Number*
Please attach a copy of a voided check*
Accepted file types: jpg, gif, jpeg, png, tga.
Consent*
I agree to the below payment policy.
I hereby authorize Merchants FoodService to initiate a charge (debit) entry at the Financial Institution indicated above, and initiate adjustments (if necessary) for any transactions debited in error. I agree that each payment shall be the same as if it were an instrument personally signed by me. This authority is to remain in effect until revoked by me in writing.

I understand, that both the Financial Institution and Merchants FoodService reserve the right to terminate this payment plan.

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Add any trade references here, preferably food distributors. Use the 'Add Another Reference' button to add more.
Reference Name*
Phone No.*
Address*
Address City State ZIP Code
Terms of Sale/Payment Terms*
Add Another Reference?*
- YES
- NO
Section Break
Reference Name*
Phone No.*
Address*
Address City State ZIP Code
Terms of Sale/Payment Terms*

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Read the terms and conditions agreement before signing and submitting the form.
Please review the application for accuracy before continuing to the next step. After clicking the Sign & Complete button, you will not be able to modify the contents of the application. To verify accuracy you may navigate through the form using the navigation buttons or by clicking the section headings.

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Thank you for your interest in becoming a customer of Merchants Foodservice.