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Business Information

Business Name

DBA (if applicable)

Business Start Date

Business Address

Type

Street 1

Street 2

City

Country

State

Zip Code

Shipping Address

Type

Street 1

Street 2

City

Country

State

Zip Code

Federal Tax ID

NY Sales Tax Certificate of Authority Number

Liquor License Number

Delivery instructions

Primary Contact

Name	Phone Number	Email Address
Add Item

Accounts Payable Contact Person

Name	Phone Number	Email Address
Add Item

Principal/Partner

Name	Title	Phone Number
Add Item

Trade References (please provide at least 2)

Name	Address	Phone Number
Add Item

Bank Reference

Name	Address	Account Number
Add Item

Credit Terms & Conditions *

In consideration of credit being extended by RESERVA, INC. to the above, the undersigned guarantor hereby agrees to personally guarantee all indebtedness owed to Reserva, Inc. Past due balances are subject to monthly finance charges of 1.5 %.

Signed by

Sign Clear

Please attach a copy of your liquor license

PDF Document

Please attach your completed Resale Certificate Form (ST-120)