Brehob Nursery, Inc.

Note: If approved, payment is to be made at the time of purchase by cash, company Visa or MasterCard, or company check. Firms wishing an open account status must apply on a separate credit application.
Customer Application - On-Line Form
*This is not* a credit application**
Applications will not be approved without a valid Indiana Nursery Dealer's License. An Indiana General Sales Tax Exemption Certificate (Form ST-105) must be submitted to us separately, before sales tax can be waived.
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Company Name: Street Address: City, State & Zip: Phone:Fax: Cell Phone:Pager: E-mail: Years in Business: Nursery Dealers License: - Federal ID Number: Indiana Retail Merchants Certificate Number: - PO REQUIRED?JOB NAME REQUIRED?Legal Status: Type of Business (Check All that Apply): Lawn Care CompanyLandscaper Wholesale NurseryGarden Center Government EntityRetail Nursery Other Authorized Buyers: Name: Position: Cell Phone: (company's main contact person) Name: Position: Name: Position: Trade References (business relationships): Please provide names of business or individuals who can substantiate that your business is a retail garden center or landscape company that does installation of plant material, i.e. commercial customers, other suppliers, equipment vendors, etc. No credit information will be asked. Name: Phone: Address: Name: Phone: Address: Name: Phone: Address:

Customer Application - On-Line Form