Corporation Name:
*
Name of the Corporation that owns a license
Trading As/DBA:
*
Name of the licensed establishment
Date Business Established:
*
-
Month
-
Day
Year
Taxpayer ID:
*
Taxation Type:
*
Taxable
Non-Taxable
Tax Exempt
License Type:
*
License
Special/Temporary Permit
NA (Non-Alcoholic)
Other Business Type:
Please Select
Adult Entertainment
Airlines / Transportation
Concessions / Stadiums
Convenience
Country / Private / Golf Club
Deli/Local Grocery
Fraternal Organization
Military
Music / Dance Club
Recreational/Bowling
Supercenter / Supermarket
Type of Business:
*
Liquor Store
Bar/Tavern/Restaurant
Hotel/Motel/Resort
Club
Catering
Other
ABC License Number:
*
Enter 12 digits without dashes
License Expiration Date:
-
Month
-
Day
Year
ABC Special/Temporary Permit #:
*
Permit Expiration Date:
-
Month
-
Day
Year
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TRADE/DBA CONTACTS & ADDRESS INFORMATION
All fields marked with an asterisk (*) are required
Primary Contact Name
*
First Name
Last Name
Primary Contact Email
*
example@example.com
Primary Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Trade/DBA Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Trade/DBA Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Trade/DBA Manager Name:
First Name
Last Name
Manager Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Manager Email:
example@example.com
Accounts Receivable (A/R) Person:
First Name
Last Name
A/R Email:
example@example.com
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OWNERSHIP
All fields marked with an asterisk (*) are required
Business Organized:
*
Corporation
Partnership
Sole Proprietorship
Limited Liability Co
Information on Principal(s)
For Proprietorship or Partnership list all owners and/or partners. For Corporation or Limited Liability Company list all officers, directors, members and majority stockholders.
1st Owner:
*
Add more?
Yes
No
2nd Owner:
Add more?
Yes
No
3rd Owner:
Add more?
Yes
No
4th Owner:
Have any companies or individuals listed above been a debtor in a bankruptcy proceeding?
*
Yes
No
Have any judgement ever been entered against any of the companies or individuals listed above
*
Yes
No
Are there any legal actions or arbitrations pending against any of the companies or individuals listed above
*
Yes
No
Have you ever held another liquor license that is now expired or do you currently own a "Pocket license"
*
Yes
No
Do you or any individuals listed above currently own any other liquor business
*
Yes
No
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CREDIT REFERENCES
All fields marked with an asterisk (*) are required
1st Reference:
*
2nd Reference:
*
3rd Reference:
*
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HOURS OF OPERATION & DELIVERY INFORMATION
All fields marked with an asterisk (*) are required
Hours of Operation
*
Rows
Open Time(HH:MM)
Open Time(AM/PM)
Close Time(HH:MM)
Close Time(AM/PM)
Monday
AM
PM
AM
PM
Tuesday
AM
PM
AM
PM
Wednesday
AM
PM
AM
PM
Thursday
AM
PM
AM
PM
Friday
AM
PM
AM
PM
Saturday
AM
PM
AM
PM
Sunday
AM
PM
AM
PM
Delivery Information
*
Rows
Preferred Delivery Time(HH:MM)
Preferred Delivery Time(AM/PM)
Latest Acceptable Time(HH:MM)
Latest Acceptable
Time(AM/PM)
Monday
AM
PM
AM
PM
Tuesday
AM
PM
AM
PM
Wednesday
AM
PM
AM
PM
Thursday
AM
PM
AM
PM
Friday
AM
PM
AM
PM
Seasonal Business
*
Yes
No
Delivery
*
Dock
Stairs
Front Door
Side Door
Basement
Special Delivery Instructions:
Please allow 24-74 hours for deliveries after placing you order (10 case minimum). Due to current economic and logistical issues, Kohler is unable to satisfy multiple orders in a given week.
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FINANCE & CERTIFICATION
All fields marked with an asterisk (*) are required
Preferred Payment Methods
*
PayLink powered by Stripe
ACH
Fintech
Check
Please include a copy of the Liquor License or proof of license transfer/resolution
*
Browse Files
Drag and drop files here
Choose a file
High resolution PDF, JPG, JPEG, PNG, GIF only, 5 MB upload size limit
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Please include a copy of the Resale Certificate ST-3 or Exempt Use Certificate ST-4 if applicable
*
Browse Files
Drag and drop files here
Choose a file
High resolution PDF, JPG, JPEG, PNG, GIF only, 5 MB upload size limit
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of
Full Legal Name of a Principal Owner
*
First Name
Middle Name
Last Name
Suffix
Today's Date
*
-
Month
-
Day
Year
By electronically signing this credit application, I'm certifying that I am the primary owner of the business in the application. I believe to the best of my knowledge that all information I have provided is accurate, true and correct.
eSignature
*
Credit email
example@example.com
Once submitted, our team will review your application as quickly as possible, and will contact you regarding next steps. Thanks again, we appreciate your business!
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