*Licensee Legal Name as shown on License

*DBA (name on signage)

*Licensee Number

*PST Number

*Billing address City and Postal Code

*Business Phone

Shipping Address including City and Postal Code (if different from billing address)

Special Delivery Instructions

*Payables Email Address

*Payables Contact Name

*Wholesale Orders Contact (manager)

Wholesale Orders email address

*Website (if you wish 40 Knots to promote wines at your location)

*Method of Payment Visa
Mastercard
Amex
EFT (must have credit card as back up payment type)
Debit (in store pick up)
Cheque (must have credit card as back up payment type)

*Name on Credit Card (legally responsible for account)

*Card number

*Expiry Date

*CVV - Card Verification Value

*Date Signed

*Agreed and Authorized by: (First Name Last Name)

*Signature (type in authorized name again)

*Title

Is there anything else you would like us to know?

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