Client Legal / Corporate Entity Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Product will be delivered to the above address? *

Yes

No

Delivery Receivable Contact Name

First Name

Last Name

Delivery Receivable Contact Phone *

(###)

###

####

Days You Can Accept Delivery

Monday

Tuesday

Wednesday

Thursday

Friday

Are your hours to accept delivery the same as your hours of operation? *

Yes

No

Operation Classification *

On Premise

Off Premise

On/Off Premise

Catering

Chain

YOUR STATE LICENSE NUMBER *

Check which box applies to your location and fill in your state license number.

Virginia ABC License No.

Maryland ATC License No.

DC ABCA License No.

Buyer Name *

First Name

Last Name

Buyer Phone *

(###)

###

####

Accounts Payable Name *

First Name

Last Name

Accounts Payable Phone *

(###)

###

####

YOUR PAYMENT TERMS *

Choose which payment terms applies to you

Virginia: COD (MANDATORY BY LAW)

Washington DC: COD for 2 months, then Terms. Click below for DC credit application

PAYMENT OPTIONS

We accept cash, checks, money orders, cashiers checks and these electronic payment options. Click any of the below options and we will email you the application. You can also find them at the end of this application.

Please email me a Fintech application

Please email me an ACH application

Please email me a MELIO application

DC Credit Application

DC clients must fill out and submit to us a credit application. We can email you the application or you can find this at the end of this form.

Please email me a DC Credit Application