Become a Customer

Location(Required)

Company's Legal Name(Required)

(e.g. Corporate Name)

Trade Name

(e.g. "Doing Business As" name)

Billing/Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Shipping Address

Street Address Address Line 2 City State ZIP Code

Contact Person(Required)

First Last

Phone(Required)

Facsimile

Form of Business(Required)

Other - Please Specify(Required)

If Sole Proprietorship or Partnership, list names, addresses, and phone numbers of all owners(Required)

Name

Address

Phone

Date of Formation(Required)

State of Formation(Required)

Federal Tax ID Number(Required)

State Sales Tax ID Number(Required)

Tobacco Sales License Number(Required)

List names, addresses, and phone numbers of all members, officers, and/or directors(Required)

Name

Address

Phone

Has the business operated under any other name in the past 6 years?(Required)

Alternative Name(Required)

Alternative Address

Has the company or any owner filed bankruptcy in the past 6 years?(Required)

Name filed under(Required)

Case Number(Required)

Court(Required)

Current Status(Required)

Has the company ever been involved in litigation with a vendor or supplier?(Required)

Name of Vendor(Required)

Address of Vendor(Required)

Court and Case Number(Required)

Status(Required)

Reason for Litigation(Required)

Names and addresses of all affiliated companies(Required)

Name

Address

(e.g. parents, subsidiaries, etc.)

Signature of Owner/Officer(Required)