CO Credit Application

Applicant Business or Corp. Name *

Billing Address *

Line 1

Line 2

City

State

Zip Code

Country

Shipping Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Business Type *

Individual Partnership Corporation LLC

Date Business Established *

Federal Tax # (For Corporation) *

Liquor License Number *

Terms *

Net 30 COD

License Expiration Date *

Preferred payment method *

Check Fintech/autopay Direct ACH 3rd Party ACH (i.e., Bill.com, Melio, Koverly, etc.)

Owner's Name *

Owner's Title *

Owner's Address *

Line 1

Line 2

City

State

Zip Code

Country

Bank Address *

Line 1

Line 2

City

State

Zip Code

Country

Maverick Sales Rep (If known) *

Premise Type *

On-premise Off-premise

Buyer/Manager Contact Name *

Phone Number *

Email *

Accounts Payable Contact Name *

Phone Number *

Email *

Delivery Instructions - Provide any information that will assist us in scheduling and delivering orders. *

Delivery Hours *

Please read and certify *

I hereby certify that the information given above is true and complete. I further certify that I have authority to bind Applicant to the following terms of this Credit Application. Per state law, Applicant agrees to pay Maverick Wine Company no later than thirty (30) days following invoice date. In the event of nonpayment after 90 days, I agree to be personally liable for any and all amounts unpaid by Applicant. Past due amounts may be subject to late fees, interest and collection costs. A $30 fee will be assessed for any returned checks. Maverick Wine Company may receive from and disclose to other persons including credit reporting agencies, information about Applicant's accounts and credit experience. Applicant authorizes any person to release to Maverick Wine Company credit experience and account information on the Applicant.

Name (Signature) *

Today's Date *

Upload copy of liquor license *

Max file size: 20MB

License pending? *

Yes, my license is pending

COLORADO CREDIT APPLICATION

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