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Customer Application

Complete the secure form below and attach your ABC License & Sales Tax Certificate. An Account Rep. will reach out within 24hrs.

If you are requesting Credit Terms (DC/MD ONLY) You must complete the personal guarantee section of this application.

If you have any questions please contact our office at 1-877-499-2602

When Using A Mobile Device Turn Device To Sign

Legal Name *

Trade Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Business Phone # *

Business Fax #

Company Email *

Website / URL

Wine Buyer Name

First

Last

Wine Buyer(s) Email

Accounts Payable Contact *

First

Last

Accounts Payable Email *

Hours of Operation *

Delivery Hours *

Delivery Instructions *

Name of Elite Wines Rep. - Optional

Enter your Sales Reps. Name here if you already have one.

Additional info you'd like to provide?

Type of Premise *

On Premise
Off Premise
On/Off Premise

Type of Location *

License Number *

Sales & Use Tax # *

Entity Type *

Corporation
LLC
Partnership
Sole Proprietorship

Social Security # (If a Sole Proprietorship) *

Federal ID# *

Names of Owners *

First

Last

Names of additional owners

First

Last

How will you be making payments? *

COD
CREDIT/TERMS DC/MD ONLY
FINTECH - VA
FINTECH - DC/MD CREDIT/TERMS

For and in consideration of the Seller (Elite Wines®) extending credit to the Applicant and with the understanding that without this Guarantee Seller would not extend such credit, the undersigned Guarantor hereby personally guarantees the payment of any obligation of the Applicant to the Seller. Therefore, Guarantor hereby agrees to pay the Seller on demand, without offset, any sum due to the Seller by the Applicant if and when Applicant fails to pay such amount. Guarantor further agrees to pay all costs of collecting including 30% attorney’s fees. This Guarantee shall be a continuing and irrevocable guarantee for indebtedness of the Applicant. Furthermore, Guarantor consents to and waives notice of any modification, amendment or extension of the credit agreement hereby guaranteed. By selecting the "Submit" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement *

First

Last

For and in consideration of the Seller (Elite Wines®) extending credit to the Applicant and with the understanding that without this Guarantee Seller would not extend such credit, the undersigned Guarantor hereby personally guarantees the payment of any obligation of the Applicant to the Seller. Therefore, Guarantor hereby agrees to pay the Seller on demand, without offset, any sum due to the Seller by the Applicant if and when Applicant fails to pay such amount. Guarantor further agrees to pay all costs of collecting including 30% attorney’s fees. This Guarantee shall be a continuing and irrevocable guarantee for indebtedness of the Applicant. Furthermore, Guarantor consents to and waives notice of any modification, amendment or extension of the credit agreement hereby guaranteed. By selecting the "Submit" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement *

First

Last

Title *

Officer
Director
Owner
Principal

Date *

Signature *

ABC LICENSE & TAX CERT *

Click or drag files to this area to upload. You can upload up to 2 files.

TAP TO TAKE A PHOTO ON MOBILE , TAKE ONE PICTURE OF EACH - PLEASE MAKE SURE IT IS CLEAR

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