Beverage New Customer

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Business Name*

Doing Business As

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is the shipping address the same as the billing address?*

Yes

Shipping Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Years in Business*

If this is a new business, please enter 0.

Business Type*

Corporation

Partnership

Sole Proprietorship

LLC

Business Phone*

Alternative Phone

Cell Phone

Business Fax

Business Email*

Purchasing Contact

Contact Name*

Contact Phone*

Contact Email*

Is the Accounts Payable contact the same as the Purchasing Contact?*

Yes

Accounts Payable Contact

Contact Name*

Contact Phone*

Contact Email*

Which type of beverages?*

Non-alcoholic

Sprits

Wine

Does your annual volume exceed 100,000 proof gallons?*

Yes

Have you obtained your TTB registry/permit numbers*

Yes

Wine Registry Number*

TTB Registry/Permit Number*

TTB Basic Permit*

Accepted file types: pdf, Max. file size: 50 MB.

Upload a PDF of the TTB Basic Permit. This is required for set-up.

Certificate of Analysis

Is a Certificate of Analysis (COA) required?

Yes

COA Contact Name*

COA Contact E-mail*

COA Requirements Upload

Accepted file types: pdf, Max. file size: 50 MB.

Upload a PDF of the Certificate of Analysis requirements

COA Requirements*

Payment Arrangements

Please select which type of payment arrangement you would like to set up and complete the appropriate sections for that payment arrangment type. Please note that if you change the selected type, all information entered for the previous payment arrangement type will be deleted.

Payment Arrangement Type*

Credit/Debit Card Agreement & Authorization

By signing this electronic form, you agree that your electronic signature is the legally binding equivalent to your handwritten signature.

Authorization*

I have read and agree to the authorization outline above

Card Type*

Visa

Mastercard

Discover

American Express

Cardholder Name*

Cardholder Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cardholder Phone*

Cardholder Email*

To provide our customers with maximum security of cardholder information, we ask that you contact us directly via phone with your credit card number. Please call Zach Collaer at (920) 886-6854 or Carolyn Skaer at (920) 886-2361.

Blanket Authorization

I authorize Galloway Company, LLC to charge the card noted above for any unpaid invoices to the business account noted above. I understand that a receipt will be emailed or direct mailed to me after the transaction is processed which will indicate the amount charged to my card and the detail of which charges the payment is for. If there are any changes to the status of the card or cardholder noted above, I agree to notify Galloway Company, LLC in writing of

Blanket Authorization (Optional)
II authorize Galloway Company, LLC to charge the card noted above for any unpaid invoices to the business account noted above. I understand that a receipt will be emailed or direct mailed to me after the transaction is processed which will indicate the amount charged to my card and the detail of which charges the payment is for. If there are any changes to the status of the card or cardholder noted above, I agree to notify Galloway Company, LLC in writing of any changes. I understand that selecting this blanket authorization method of payment eliminates the need for any written or telephone communication for the transaction to be processed. This blanket authorization will remain in effect until further written notice by me.

Authorization for Direct Payment (ACH)
I authorize the financial institution named below to allow charges initiated by Galloway Company, LLC from my checking/savings account. This authorization will remain in effect until I notify, in riting, to cancel it in such time as to afford the financial institution a reasonable opportunity to act on it. I can stop payment on any entry by notifying my financial institution 3 business days before my account is charged.
I further authorize Galloway Company, LLC, 601 S. Commercial Street, Neenah, WI 54956 to initiate electronic entries from my checking/savings account and have agreed to the terms listed on this authorization. I may revoke my authorization with Galloway Company, LLC at any time in writing and send it to the address above.
Regular payments will be withdrawn from the account(s) authorized below weekly on Fridays, or the first business day after those dates. Amounts withdrawn will vary based on invoice amounts. Notification of payments to be withdrawn along with the detail of which invoices payment has been applied to, with discounts applied as well as the total amount being charged will be sent on Monday, with payments being charged to the account(s) on Friday of that week. (Days of the week funds are drawn are negotiable.)
TERMS: I authorize Galloway Company, LLC to deduct amounts from the account(s) listed below to pay current invoices on the accounts of:

Authorization*
I have read and agree to the authorization outline above

Name of Financial Institution*

Name on Account*

Branch Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Routing Number*

Account Type*

Checking

Savings

Email Address for Receipt*

Voided Check
Max. file size: 50 MB.
Please attach a PDF copy of a voided check for this account. Do not use a deposit ticket.

If you have questions regarding payment arrangements, please contact Carolyn Skaer at (920)886-2361.

Credit Application
The undersigned hereby authorizes Galloway Company, LLC to obtain information relating to bank accounts from any bank listed below at any time, and to obtain updates of such information from time to time, without further notice to the undersigned. This consent shall continue in force and effect until it is revoked, in writing, by the undersigned. By signing this electronic form, you agree that your electronic signature is the legally binding equivalent to your handwritten signature.

Authorization*
I have read and agree to the authorization outline above

Bank Name*

Account Number*

Bank Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Bank Contact

Contact Name*

Contact Phone*

Contact Email*

Credit References
Please list only companies who have a credit history with you.

References Upload
Max. file size: 50 MB.
Upload a PDF of credit references that includes the company name, address, phone number, and email. Uploading a PDF will hide the reference text fields

Did you upload references?*

Yes

No

Reference 1

Company Name**

Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Fax

Reference 2

Company Name**

Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Fax

Reference 3

Company Name**

Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Fax

Owner Information

Name*
First Middle Last

Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Terms and Conditions
The undersigned warrants that the above information is true and complete, that Applicant is financially able to meet all commitments made with Galloway Company, LLC (“Company”) and agrees to the following: All invoices are due according to the terms as stated on the invoice. Credit terms begin on the date of the invoice.

Company reserves the right to change the credit terms at its discretion on notice to Applicant.

In the event any invoice is not paid when due, Applicant agrees to pay all costs of collection, including Company's actual attorneyʼs fees and interest at a rate of 18% APR .

Any action between the parties, including any action for the collection of past-due invoices, shall be governed by Wisconsin law and shall be brought in Winnebago County, Wisconsin.

The undersigned warrants that he/she is authorized to enter into this Application and Agreement on behalf of the Applicant. By signing this electronic form, you agree that your electronic signature is the legally binding equivalent to your handwritten signature.

Authorization*
I have read and agree to the terms outline above

Consent to Obtain Credit Information The undersigned hereby authorizes Galloway Company, LLC to obtain credit information concerning his/her personal credit from any third party, including a credit report agency, at any time, and to obtain updates of such information from time to time, without further notice to the undersigned. This consent shall continue in force and effect until it is revoked, in writing, by the undersigned. By signing this electronic form, you agree that your electronic signature is the legally binding equivalent to your handwritten signature.

Authorization*
I have read and agree to the terms outline above

PERSONAL GUARANTEE
To induce Galloway Company, LLC to extend credit terms to Applicant, the undersigned guarantees all obligations and liabilities of every kind and description arising out of credit granted by Classic Mix Partners, LLC to Applicant at any time prior to the receipt by Galloway Company, LLC of written notice of revocation by Guarantor, including interest and charges (the "Obligations"), and to the extent not prohibited by law, all costs, expenses and fees (including attorney's fees) at any time paid or incurred in endeavoring to collect all or part of the Obligations, or to realize upon this Guaranty. To the extent not prohibited by law, the undersigned expressly waive notice of acceptance, the creation of any Obligation, default under any Obligation, proceedings to collect from any party, and all diligence of collection and presentment, demand, notice and protest. Guarantor consents to personal jurisdiction and venue in Winnebago County, Wisconsin in any action to enforce this guaranty. By signing this electronic form, you agree that your electronic signature is the legally binding equivalent to your handwritten signature.
Guarantor 1
Name
Date
MM slash DD slash YYYY

Signature
Guarantor 2
Name
Date
MM slash DD slash YYYY

Signature

Sales Tax Exemption Form*
Max. file size: 50 MB.
Please upload a PDF copy of your completed Sales Tax Exemption form.

Signature
By signing this electronic form, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Additionally, by signing below, you are reaffimring the selected agreements throughout this form, you are warranting that you are authorized to enter into those agreements on behalf of the applicant, and you are certifying that the provided information is true and correct.
Submitted By*
Title*
Authorized Signature*
Date*
MM slash DD slash YYYY

Beverage New Customer

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