NEW CUSTOMER FORM

Company Name

DBA and Years in Business

Shipping Address

Billing Address

Phone

(###)

###

####

Fax

(###)

###

####

Accounts Payable Contact Name and Phone Number

Email

Permittee Name

Ct. Sales Tax I.D. Number (i.e.-000)

Liquor License Number and Expiration Date

Landlord Information (ONLY APPLICABLE FOR CUSTOMERS WITH SODA SYSTEM):

STREET ADDRESS CITY STATE ZIP CODE TELEPHONE FAX

SS #

**Customers seeking 30 day terms please provide Social Security number for credit approval