New Client – Nafta

COMPANY NAME

DATE

STREET

CITY

STATE

ZIP CODE

STREET

CITY

STATE

ZIP CODE

PHONE

FAX

TYPE OF BUSINESS

DATE ESTABLISHED

NAME OF OWNER

TAX EXEMPT #

FEDERAL ID #

LIQUOR LICENSE #

UPLOAD LIQUOR LICENSE AND SELLER'S PERMIT

SELECT OPTION BELOW

BANK NAME

CONTACT

BRANCH

PHONE

ACCOUNT #

LOANS (Y/N)

SECURED (Y/N)

Valid Customer Accounts Only

Reference #1

NAME

CONTACT

ADDRESS

PHONE

CITY

STATE

ZIP CODE

Reference #2

NAME

CONTACT

ADDRESS

PHONE

CITY

STATE

ZIP CODE

Reference #3

NAME

CONTACT

ADDRESS

PHONE

CITY

STATE

ZIP CODE

PRINT NAME

SING

TITLE

DATE

I AGREE TO PAY THE TERMS GRANTED AND IN CASE OF DEFAULT AND/OR ARBITRATION I WILL BE RESPONSIBLE TO NAFTA DISTRIBUTORS FOR ALL EXPENSES ASSOCIATED WITH COLLECTIONS, ATTORNEY AND COURT FEES. I AUTHORIZE NAFTA DISTRIBUTORS TO MAKE INQUIRIES ON THE REFERENCES PROVIDED FOR THE PURPOSE OF ESTABLISHING A NEW ACCOUNT WITH NAFTA DISTRIBUTORS.