New Account Setup

Credit Application must be completed for Line of Credit

Locations

Bismarck, ND
Bowman, ND
Dickinson, ND
Mandan, ND

Minot, ND
Jamestown, ND
Grand Forks, ND
Williston, ND
Brandon, SD

Mapleton, ND
West Fargo, ND
Bemidji, MN
Fergus Falls, MN

PO BOX 6247
1615 BISMARCK EXPRESSWAY
BISMARCK ND 58506-6247
(701) 221-9600
Fax: (701) 224-7299
E-mail: [email protected]

Salesman #(Required)

Loc # Ordering From(Required)

Route Code

Date

Bill to Address

Business / Customer Name(Required)

Contact Person(Required)

First Last

Position

Address(Required)

Street Address City State ZIP Code

Phone #(Required)

Mobile #

Email Notification Information

Email Address(Required)

Email Options

Statements

Invoices

Flyers

Email Address (2)

Email Options (2)

Statements

Invoices

Flyers

Setup Online Access?

Yes

No

PO Required(Required)

Yes

No

Unit # Required(Required)

Yes

No

Retread Customer

Yes

No

Price Code

Account Type(Required)

Description of Company(Required)

Create Price Support

Yes

No

Method of Payment

Method of Payment

Cash/Check

C/C on File

Charge Account

Estimate of Monthly Sales

Special Requests: By Vendor, Product, Class

Competition (Notes)

Notes