NEW CUSTOMERS - ELITE WINES

Customer Application

Complete the secure form below and attach your ABC License & Sales Tax Certificate. Your sales rep will reach out within 24hrs. If you are requesting Credit Terms (DC/MD Only) You must complete the personal guarantee section of this application.

If you have any questions please contact our office at 1-877-499-2602

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Legal Name *

Trade Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Business Phone # *

Business Fax #

Company Email *

Website / URL

Wine Buyer Name

First

Last

Wine Buyer(s) Email

Accounts Payable Contact *

First

Last

Accounts Payable Email *

Hours of Operation *

Delivery Hours *

Delivery Instructions *

Additional info you'd like to provide?

Enter your Sales Reps. Name here if you already have one.

Type of Premise *

On Premise
Off Premise
On/Off Premise

Type of Location *

License Number *

Sales & Use Tax # *

Entity Type *

Corporation
LLC
Partnership
Sole Proprietorship

Federal ID# *

Names of Owners *

First

Last

Names of additional owners

First

Last

How will you be making payments? *

COD
CREDIT/TERMS
FINTECH - DC/MD CREDIT/TERMS
FINTECH - VA

Title *

Officer
Director
Owner
Principal

Date *

Signature *

ABC LICENSE & TAX CERT *

Click or drag files to this area to upload. You can upload up to 2 files.