New Customer Setup Form

Fields marked with a * are required.

Is this Account for an Individual/Family, Business, or Buying Club?(Required)

If Individual/Family/Buying Club would you prefer home delivery or warehouse pickup?(Required)

Email (will also be your Username to login)(Required)

This field is hidden when viewing the form

Username(Required)

Password(Required)

Passwords must contain letters, numbers and a symbol

Enter Password Confirm Password

Strength indicator

Business Name(Required)

What type of business are you?(Required)

If other, please best describe your business type(Required)

First Name(Required)

Last Name(Required)

Your Phone Number(Required)

Alternate or Mobile Phone

Billing Address(Required)

Street Address Address Line 2 City State Zip Code

Delivery Address(Required)

Click here if same as billing address

Street Address Address Line 2 City State Zip Code

Accounts Payable Name

Accounts Payable Email

Accounts Payable Phone Number

ACH authorization options(Required)

We encourage you to set up your ACH information here, this will expedite your set up process dramatically, however, if you are not comfortable submitting payment info via our secure server, you can select no below and we will contact you via phone to finalize payment terms.

Name of Financial Institution(Required)

Address of Financial Institution(Required)

Street Address Address Line 2 City State Zip Code

Financial Institution Routing Number(Required)

Financial Institution Account Number(Required)

Upload a copy of a voided check(Required)

Please snap a photo of a voided check (clearly showing the routing and account number), save to your computer and then upload the file here.

Max. file size: 50 MB.

Date of signature of consent(Required)

Tax ID#(Required)

ST-120 forms or copies of certificate of authority(Required)

Please submit your resale certificate or tax exemption form if you are are tax exempt

Max. file size: 50 MB.

Hours of Operation

Delivery and Receiving Hours(Required)

REQUIRED: Delivery and Receiving Hours(Required)

Is there a loading dock?

Can your location accept delivery by a 53' tractor trailer?

Can your location accept delivery by a straight truck?

What does our driver need to know to successfully deliver to your location?(Required)

REQUIRED: What does our driver need to know to successfully deliver to your location?(Required)

How did you hear about Regional Access?

Thank you for choosing warehouse pickup!

Please click this link to review our procedures for picking up from our warehouse.

Automated Email Opt In

Seasonal Produce Availability?

Sales and new products?

Special Events?

Please check all that apply.

CAPTCHA

New Customer Setup Form

*Please note, if you have shopped with us before, your account has already been created–please do not create a duplicate account. You should have received an email from us with instructions for resetting your account credentials, you can log in here. If you are unable to locate those instructions or need assistance logging in, please contact us.

Is this Account for an Individual/Family, Business, or Buying Club?(Required)

If Individual/Family/Buying Club would you prefer home delivery or warehouse pickup?(Required)

Email (will also be your Username to login)(Required)

This field is hidden when viewing the form

Username(Required)

Password(Required)

Passwords must contain letters, numbers and a symbol

Enter Password Confirm Password

Strength indicator

Business Name(Required)

What type of business are you?(Required)

If other, please best describe your business type(Required)

First Name(Required)

Last Name(Required)

Your Phone Number(Required)

Alternate or Mobile Phone

Billing Address(Required)

Street Address Address Line 2 City State Zip Code

Delivery Address(Required)

Click here if same as billing address

Street Address Address Line 2 City State Zip Code

Accounts Payable Name

Accounts Payable Email

Accounts Payable Phone Number

ACH authorization options(Required)

Name of Financial Institution(Required)

Address of Financial Institution(Required)

Street Address Address Line 2 City State Zip Code

Financial Institution Routing Number(Required)

Financial Institution Account Number(Required)

Upload a copy of a voided check(Required)

Please snap a photo of a voided check (clearly showing the routing and account number), save to your computer and then upload the file here.

Max. file size: 50 MB.

Date of signature of consent(Required)

Tax ID#(Required)

ST-120 forms or copies of certificate of authority(Required)

Please submit your resale certificate or tax exemption form if you are are tax exempt

Max. file size: 50 MB.

Hours of Operation

Delivery and Receiving Hours(Required)

REQUIRED: Delivery and Receiving Hours(Required)

Is there a loading dock?

Can your location accept delivery by a 53' tractor trailer?

Can your location accept delivery by a straight truck?

What does our driver need to know to successfully deliver to your location?(Required)

REQUIRED: What does our driver need to know to successfully deliver to your location?(Required)

How did you hear about Regional Access?

Thank you for choosing warehouse pickup!

Please click this link to review our procedures for picking up from our warehouse.

Automated Email Opt In

Seasonal Produce Availability?

Sales and new products?

Special Events?

Please check all that apply.

CAPTCHA

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New Customer Setup Form

New Customer Setup Form