SLSM#

SLSM Name

Profile

Retailer ID

Mandatory field DBA Name*

Mandatory field Licensee Name*

Mandatory field Street Address*

Mandatory field City*

Mandatory field State*

Mandatory field ZIP Code*

Mandatory field County*

Mandatory field Phone Number*

Mandatory field Buyer*

Mandatory field License*

Transfer Original

Formerly

Account Number

Name

Delivery/Call Days

Delivery Days

Monday Tuesday Wednesday Thursday Friday

Call Days

Monday Tuesday Wednesday Thursday Friday

Licensing

Mandatory field Licence Number*

MSS Number

License Number 2

SLSREP Number STAT

Mailing Address

Mandatory field Address*

Address 2

Mandatory field City*

Mandatory field State*

Mandatory field ZIP Code*

Market Demographics

Mandatory field Market Type* Sports Bar Private Club Bar / Tavern Adult Entertainment Military / ON Airline / Transportation Casino / Gamble Restaurant Hotel / Motel Golf / Country Club Bowling Center Music Dance Concession Special Event Supermarket Super Center Neighborhood Grocery Drug Store Liquor Store Wholesale Military / OFF Convenience / GAS Non-alcohol

Package Consumption Type

Yes No

Draft Consumption Type

Yes No

Accounts Receivable

Mandatory field Tax ID*

Delivery Instructions

Additional Service Instructions

Invoicing

Duplicate Invoice Option

Yes No

Licence

Upload Licence Photo