New Retail Partner

Legal Business Name*

DBA

Primary Contact Name*

Primary Contact Email*

Primary Contact Phone Number*

Receiving Manager Contact*

Receiving Manager Email*

Receiving Manager Phone Number*

Preferred Contact Method For Delivery Confirmation*

Business Address*

City, Zip*

Delivery Address
If different than store address

Delivery City, Zip
If different than store address

Receiving Hours (AM/PM)*

What type of license do you hold?*
RetailRetail/DeliveryDistributionMicrobusinessOther

Attach License*

Attach Sellers Permit*

Payment Method*
Cash

Payment Terms*
CODNet 14Net 30

Federal EIN Number (Tax ID)*

Name
If person submitting this form is different than primary contact

Email Address
If person submitting this form is different than primary contact