Credit Application

Corporate Name *

d/b/a

Address

City

ZIP Code

State

Phone *

Fax

Contact Name *

Email *

AP Contact Name *

Email *

License Serial Number *

Sales Tax Resale Number *

Federal EIN / Tax ID *

Delivery Window

Delivery Instructions

Please attach a copy of your liquor license

Attach existing credit application

Attach resale certificate (ST-120 form)

Consent for storing submitted data *

Yes, I give permission to store and process my data