Trade Name
This Business is (Please Check One) On Premise Off Premise
Liquor Licensee
Agent Name if Licensee is not an Individual
Contact (or Buyers) Name
Please check what type of legal entity the business is Sole-Proprietorship Partnership Corporation LLC LLP
If business is a Sole-Proprietorship, please type the name and address of owner:
If business is a Partnership, Corporation, LLC, or LLP type its legal name:
If the business is not a Sole-Proprietorship, please type the name(s) and home address(es) of the officers:
Business Address City State Zip
Business Phone
Business Fax
Federal Tax ID #
Wisconsin Sellers Permit #
Liquor License Renewal (MM/DD/YYYY)
License Number
Fill in the name of the municipality who is issuing the liquor license City of Town of Village of
Mailing Address - if different from delivery address Name Address City State Zip
Account Type (please check one) On Premise Accounts Bar/Tavern/Lounge Bowling Center Chain Restaurant (National) Restaurant - Fine Dining Night Club (Urban) Caterer's Banquet Chain Restaurant (Local) Restaurant - Casual Theme Private Club Hotel/Resort Other: Off Premise Accounts Chain Liquor Store Chain Grocery Store Convenience Store Independent Liquor Store Independent Grocery Store Non Merchandise Wholesale Club Other:
Is this account part of a chain? No Yes If yes, the name of the chain:
Account Ethnicity (please check one) Caucasian Italian German African American Japanese/Chinese Polish Hispanic Greek Slavic Asian French Other:
Account Classification (please check one) A B C Other
Does the account want invoices split? No Yes If yes, please check the appropriate split below (the "/" splits the invoice, the "&" includes on any invoice) Liquor/Wine/Malt/Non Alch Liquor & Wine & Malt/Non Alch Liquor/Wine & Malt/Non Alch Liquor & Wine/Malt/Non Alch Liquor/Wine & Malt & Non Alch
Specific Delivery Instructions: