New Customer Form

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Business Phone Number *

(###)

###

####

Contact Person *

First Name

Last Name

Alternative Phone Number

(###)

###

####

What days will you accept deliveries? *

Monday

Tuesday

Wednesday

Thursday

Friday

What type of establishment?

Beverage Store

Grocery Store

Restaurant

Hybrid (on/off premise license)

Are you interested in signing up for EFT payments via Fintech?

Yes

No