New Retailer Link - Kay Distributing

Credit Terms Requested:

Full Legal Name of Owner:

First

Middle

Last

Phone #:

Corporation Name:

Fax #:

DBA(if different):

Email:

Email

Confirm Email

Physical Address:

Address Line 1

Address Line 2

City

State

Zip Code

Bill to Address (Different than above)

Address Line 1

Address Line 2

City

State

Zip Code

Type of Company

Corporation
Partnership
Limited Liability Company
Sole Proprietor

Other Types of Companies

Specify Here

Carry Draft Beer?

Yes
No

Town, County, Village Etc that holds Liquor License:

Seasonal Account?

Yes
No

Name and Address of person on Liquor License:

Name On Liquor License:

First

Last

Address on Liquor License:

Address Line 1

Address Line 2

City

State

Zip Code

Liquor License:

Liquor License #:

Sellers Permit #:

Usually, this number starts with a 456-

Exp. Date:

All statements are emailed. If you would like to receive a statement, please include you email here:

Email

Confirm Email

Ownership Information:

Owners Name

Ownership%:

Contact Phone #:

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Owners Name

Ownership %:

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Owners Name

Ownership %:

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Owners Name:

Ownership %:

Contact Phone #:

Title

Home Address:

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Title

Home Address:

Contact Phone #:

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Title

Home Address:

Contact Phone #: (copy)

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Title

Home Address:

Bank Reference:

Name of Bank:

Phone #:

Account #:

Bank Address:

Contact Name:

Type of Account:

Please list three significant relationships you have had for at least three years:

List their Name, Address, Phone #, and Contact above.

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Do you own the premises that the business occupies?

Yes
No

Mortgage Holder/Landlord Name:

Phone #:

Years at Location:

Contact Person:

Address:

Has the company or any officer, partner, member, or owner ever filed for bankruptcy?

Yes
No

If yes, attach detail below:

Has your company or any company that any officer, partner, member or owner been associated with as an officer, partner, member, or owner ever had credit with us before?

Yes
No

If yes under what name?

Enter name here

By signing below, I certify that I have the authority to bind the company to this agreement, and that I agree to creditor's terms or sale of 15 days, I also agree and accept that the credit limit and credit terms may be changed or withdrawn at the sole discretion of the creditor. Creditor shall include creditor subsidiares, related companies, and assigns. The information given herein is offered as part of a request by the applicant for an extension of credit for commercial business use. The information provided is represented by the applicant to be true, correct, and complete. The applicant authorizes creditor to investigate all credit references and other sources pertaining to our credit and financial responsibility. The undersigned authorizes its banks and trade creditors to provide creditor with complete information for the purpose of credit evaluation. The applicant understands that account will be non deliverable if past due. The applicant further agrees to pay collection charge in the event of default, if the account is placed with a collection agency or attorney.

Sign below this section

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Applicant Company Name:

Signature:

Title:

Date:

Personal Guarantee / Signature / Date / Date of Birth

In consideration of any credit extended, the undersigned will personally guarantee full and prompt payment or all indebtedness of owed to Kay Beer Distributing Inc. This personal guarantee shall remain in force until its revocation is received by certified mail to the address and attention of 1881 Commerce Drive, De Pere, WI 54115 Attention Accounts Receivable. Revocation shall not affect indebtedness incurred prior to receipt of written notice. For credit terms with Kay Beer Distributing, the personal guarantee section must be signed above.

New Retailer Account Setup Form

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