General Information

Today's Date:

Business type:
Corporation/LLCPartnershipSole ProprietorLiquor Licensee

Name of Business:

DBA (if different from above)

Business EIN:

Year established:

If incorporated, under which state:

Street Address:

City:

State:

Zip Code:

Business phone:

Business fax - optional:

Email Address **Required Field**:

Name on License:

License Number:

Business Owners

Owner #1 Information

Name:

Street Address:

City:

State:

Zip Code:

Phone Number:

Email Address:

Social security number:

Percent ownership:

Owner #2 Information

Name:

Street Address:

City:

State:

Zip Code:

Phone Number:

Email Address:

Social security number:

Percent ownership:

Owner #3 Information

Name:

Street Address:

City:

State:

Zip Code:

Phone Number:

Email Address:

Social security number:

Percent ownership:

Owner #4 Information

Name:

Street Address:

City:

State:

Zip Code:

Phone Number:

Email Address:

Social security number:

Percent ownership:

Financial Information

Name of Accounts payable contact:

Contact email:

Contact phone number:

Email to mail statements to:

Check here if email is the same as above in general information

Mailing address to mail statements to:

Check here if address is the same as above in general information

Estimated sales in the next 6 months:

Amount of credit requested:

Do you have lines of credit with other distributors?
YesNo
If yes, which ones
Southern Glazer Wine and SpiritsEpicOther
Other:

Are there any lawsuits pending?
NoYes - I am the plaintiffYes - I am the defendant

References

Names of business/trade references

Reference # 1

Name:

Street Address:

City:

State:

Zip Code:

Phone Number:

Email Address:

Reference # 2

Name:

Street Address:

City:

State:

Zip Code:

Phone Number:

Email Address:

Terms and Conditions

Please read the following carefully before accepting.

Applicant represents that applicant has read, understands and consents to the provisions of the Credit Agreement set forth on the following pages of this Credit agreement. Applicant authorizes investigation and disclosure of information of credit application including checking credit history with credit bureaus and others. All payments will be expected in accordance with NRS 369.485, otherwise COD will be expected.

I hereby warrant that the above information is true and correct and is furnished for the purpose of obtaining credit. I hereby agree that The Wine Noire, LLC may investigate our record and that, if an account is opened, The Wine Noire, LLC may furnish information regarding this account to credit reporting agencies and others who may properly request such information. My signature below authorizes any and all agencies listed on this application as a credit reference to release information about our company’s history with them.

CREDIT TERMS: Net 30 days. Interest of 1 1⁄2 percent per month shall accrue on any unpaid balance of applicant’s account, which is not paid to the company according to the terms of payment specified by the company. In the event that the account is placed with a collection agency or attorney for collection, applicant agrees to pay all costs of collection, including reasonable attorney fees, whether or not a lawsuit is commenced.

In the event an action is commenced, applicant hereby submits to the jurisdiction of the courts of California. Applicant hereby authorizes the company to obtain credit information from any source and further authorizes those credit sources to provide credit information to the company.

Applicant understands that delinquent payments may jeopardize my credit privileges.

Applicant

Applicant's Name:


By clicking this box the applicant accepts the terms and conditions

Distributor

Distributor's Name:

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