Today’s Date

Submitted by

Business Name (d.b.a)

Store #

Address

City, State

Tel

Fax

Store Contact Person

Email

A/P Contact

Mailing Address

same as above

Tel number

Starting service date

Distributor

Cash
Charge
COD

Business name

Tel

Address

Contact

Bank name

City

Acct #

Tel Number

We agree in having a net 14, and to comply with Casa Sanchez Foods payments terms in consideration in receiving credit terms.

Signed

Title