EmailMe Form - New Account Application

Business Information

Legal Business Name *

DBA *

Business Shipping Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Business Phone # *

### - ### - ####

Federal Tax ID *

Delivery Information

Delivery Days

Tuesday

Wednesday

Thursday

Friday

Please select all days deliveries will be accepted and note times & instructions in box to the right

Delivery Times & Instructions *

Ownership Information

Owner Name *

First Last

Length of Ownership (yrs) *

Contact/Buyer Name (if different)

First Last

Contact Phone

### - ### - ####

Contact Email *

Accounts Payable Name

First Last

Accounts Payable Email

Reference Information

Bank Name *

Bank Phone *

### - ### - ####

Bank Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Business Reference 1 *

Phone *

### - ### - ####

Business Reference 2 *

Phone *

### - ### - ####

Please include a copy of current liquor license.

*** Failure to provide will result in delay of establishing account ***

Attestation and Signature

Applicant's Signature attests financial responsibility, ability and willingness to pay invoices in accordance with the following terms:

1) Applicant certifies that all statements made in this Application are true and correct, and made for the purpose of obtaining credit. Applicant authorizes parties named above to release credit information to Atlantic Beverage Distributors or it's agents for the purpose of conducting a credit check.

2) Invoices are net 60 days. Balances over 60 days are subject to a service charge of 1.5% per month (18% per annum). A 1% discount may be taken for invoices paid within 10 days of delivery. Applicant will be assessed a $50 fee for all returned checks.

3) If Applicant's account is submitted to an attorney for collections, Applicant agrees to pay all costs of collection, including but not limited to, reasonable attorney's fees.

Applicant's Name *

First Last

Applicant's Title *

Authorized Signature *

Clear