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New Customer Registration Form
Establishment Name
(Required)
Licensee Name
(Required)
Address (Street, City, Zip Code)
(Required)
County
(Required)
Location Phone
(Required)
Email
(Required)
Off Premise=SDM (Beer & Wine) SDD (Liquor) or On Premise=CLASS B or C, or Tavern#
(Required)
If on premise, number of taps
Business ID#
(Required)
Effective Date
(Required)
Month
Month
Day
Year
Expiration Date
(Required)
Month
Month
Day
Year
Contact Person (First and Last Names)
(Required)
Contact Person Phone
(Required)
Open Time
Time
:
AM
Delivery Day
Monday
Tuesday
Wednesday
Thursday
Friday
Delivery Time Start
Time
:
AM
Delivery Time End
Time
:
AM
Premise
On
Off
RVM (Empties)
Yes
No
Which Type
Company Using
Submit
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